Provider Demographics
NPI:1437226768
Name:MANDAC, LOURDES C (MD)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:C
Last Name:MANDAC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 POST LANE
Mailing Address - Street 2:
Mailing Address - City:PALISADES
Mailing Address - State:NY
Mailing Address - Zip Code:10964-0237
Mailing Address - Country:US
Mailing Address - Phone:845-359-1642
Mailing Address - Fax:
Practice Address - Street 1:140 OLD ORANGEBURG RD
Practice Address - Street 2:ROCKLAND PSYCHIATRIC CENTER
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-1157
Practice Address - Country:US
Practice Address - Phone:845-680-8562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140038-1208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF40322Medicare UPIN