Healthcare Provider Details

I. General information

NPI: 1376632208
Provider Name (Legal Business Name): DAVID ROBERT MANDY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46600 ROMEO PLANK RD SUITE 4
MACOMB MI
48044-5741
US

IV. Provider business mailing address

46600 ROMEO PLANK RD SUITE 4
MACOMB MI
48044-5741
US

V. Phone/Fax

Practice location:
  • Phone: 586-228-5437
  • Fax: 586-228-7520
Mailing address:
  • Phone: 586-228-5437
  • Fax: 586-228-7520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDM006689
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: