Provider Demographics
NPI:1073074001
Name:MANDILE, KELLY L (DPM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MANDILE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:CAPUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1506 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-4071
Mailing Address - Country:US
Mailing Address - Phone:864-725-7430
Mailing Address - Fax:864-725-7431
Practice Address - Street 1:1506 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4071
Practice Address - Country:US
Practice Address - Phone:864-725-7430
Practice Address - Fax:864-725-7431
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC745213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery