Basic Information
| Provider Information | |||||||||
| NPI: | 1457455990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDELKORN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | MARC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3033 WINKLER AVENUE EXT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399393939 | ||||||||
| FaxNumber: | 2399316106 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 WINKLER AVENUE EXT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399393939 | ||||||||
| FaxNumber: | 2399316106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME80929 | FL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | AM9445734 | 01 | DEA NUMBER | OTHER |