Healthcare Provider Details

I. General information

NPI: 1669408696
Provider Name (Legal Business Name): DAVID E MANDELBAUM MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 03/11/2023
Certification Date: 03/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARK ST
NEW HAVEN CT
06504-8901
US

IV. Provider business mailing address

237 IRVING AVE
PROVIDENCE RI
02906-5518
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-4081
  • Fax: 203-737-7635
Mailing address:
  • Phone: 401-595-3467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number151239
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number151239
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberMD11065
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberMD11065
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number64335
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number151239
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License NumberMD11065
License Number StateRI
# 8
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number70147
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: