Provider Demographics
NPI:1073501821
Name:MANDAVA, VASUDEVARAO (MD)
Entity Type:Individual
Prefix:DR
First Name:VASUDEVARAO
Middle Name:
Last Name:MANDAVA
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 1:6800 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1167
Mailing Address - Country:US
Mailing Address - Phone:586-619-9986
Mailing Address - Fax:
Practice Address - Street 1:18 MARKET ST
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043
Practice Address - Country:US
Practice Address - Phone:586-783-2222
Practice Address - Fax:586-783-6280
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVM031566207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1096276Medicaid
MIE35348Medicare UPIN
MI1096276Medicaid