Provider Demographics
NPI:1487786927
Name:MANDELKERN, MARSHAL (MD)
Entity type:Individual
Prefix:DR
First Name:MARSHAL
Middle Name:
Last Name:MANDELKERN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BRADLEY RD STE 403
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2235
Mailing Address - Country:US
Mailing Address - Phone:203-387-1102
Mailing Address - Fax:203-387-1308
Practice Address - Street 1:1 BRADLEY RD STE 403
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2235
Practice Address - Country:US
Practice Address - Phone:203-387-1102
Practice Address - Fax:203-387-1308
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT261132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E31718Medicare UPIN