Provider Demographics
NPI:1114004413
Name:MANDRIS, LOUIS ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:ROBERT
Last Name:MANDRIS
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 1:22825 BRENFORD ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-4909
Mailing Address - Country:US
Mailing Address - Phone:818-564-4647
Mailing Address - Fax:
Practice Address - Street 1:22825 BRENFORD ST
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-4909
Practice Address - Country:US
Practice Address - Phone:818-564-4647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55865174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA260640306OtherEMPLOYER IDENTIFICATION NUMBER
CAA53046Medicare UPIN
CA491274Medicare ID - Type Unspecified