1114981818 NPI number — DR. VANESSA JAIASHREE MANDAL MD

Table of content: DR. VANESSA JAIASHREE MANDAL MD (NPI 1114981818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114981818 NPI number — DR. VANESSA JAIASHREE MANDAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANDAL
Provider First Name:
VANESSA
Provider Middle Name:
JAIASHREE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114981818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 DATA DRIVE
Provider Second Line Business Mailing Address:
PHYSICIAN SUPPORT SERVICES
Provider Business Mailing Address City Name:
RANCHO CORDOVA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95670-7956
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-379-2948
Provider Business Mailing Address Fax Number:
916-858-7065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2110 PROFESSIONAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-536-2500
Provider Business Practice Location Address Fax Number:
281-545-1442
Provider Enumeration Date:
04/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  M1435 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: C55495 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 178386201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8G6218 . This is a "BC/BS TX#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00301395 . This is a "RAILROAD GBA - RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: MD1435TX . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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