Provider Demographics
NPI:1104002872
Name:MANDAL, RONNIE RANJAN (DO,MBA,MS,MT(ASCP))
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:RANJAN
Last Name:MANDAL
Suffix:
Gender:M
Credentials:DO,MBA,MS,MT(ASCP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 N FRANCISCO AVE
Mailing Address - Street 2:FL 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3611
Mailing Address - Country:US
Mailing Address - Phone:773-271-6622
Mailing Address - Fax:773-271-6801
Practice Address - Street 1:5115 N FRANCISCO AVE
Practice Address - Street 2:FL 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3611
Practice Address - Country:US
Practice Address - Phone:773-271-6622
Practice Address - Fax:773-271-6801
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-12
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119779207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
R02273Medicare PIN