Healthcare Provider Details

I. General information

NPI: 1972066397
Provider Name (Legal Business Name): MAX MANDELBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 CHENOWETH LN
LOUISVILLE KY
40207-2651
US

IV. Provider business mailing address

132 CHENOWETH LN
LOUISVILLE KY
40207-2651
US

V. Phone/Fax

Practice location:
  • Phone: 502-584-1109
  • Fax: 502-901-1830
Mailing address:
  • Phone: 502-584-1109
  • Fax: 502-901-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number62108
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number328018-01
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35.153304
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0101289109
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: