=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386674794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE M MANDRY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 12/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1510 CITRUS MEDICAL CT
-----------------------------------------------------
City | OCOEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34761-4547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-480-4830
-----------------------------------------------------
Fax | 407-480-4834
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1510 CITRUS MEDICAL CT
-----------------------------------------------------
City | OCOEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34761-4547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-480-4830
-----------------------------------------------------
Fax | 407-480-4834
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 0062303
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------