Provider Demographics
NPI:1104043249
Name:MANDANIS, PERRY NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:NICHOLAS
Last Name:MANDANIS
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 1:189 N BIGELOW RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06247-1408
Mailing Address - Country:US
Mailing Address - Phone:860-455-1119
Mailing Address - Fax:
Practice Address - Street 1:189 N BIGELOW RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06247-1408
Practice Address - Country:US
Practice Address - Phone:860-455-1119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0427392084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry