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General NPI Number Information
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NPI Number | 1295153716
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Entity Type | Organization
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Legal Business Name | JEFFREY D MANDELKORN PHD PA
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Dates
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Enumeration Date | 04/01/2014
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Last Update Date | 07/24/2014
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Provider Practice Location Address
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Address Line | 2000 NE 17TH ST #3
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City | FORT LAUDERDALE
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State | FL
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Zip | 33305-2565
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Country | US
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Telephone | 954-661-3673
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Fax |
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Provider Business Mailing Address
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Address Line | 2000 NE 17TH ST #3
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City | FORT LAUDERDALE
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State | FL
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Zip | 33305-2565
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Country | US
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Telephone | 954-661-3673
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JEFFREY D MANDELKORN
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Credential | PHD
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Telephone | 954-661-3673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | PY 8957
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License Number State | FL
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