Provider Demographics
NPI:1114239639
Name:MEHRA, MANDIRA N (MD)
Entity Type:Individual
Prefix:
First Name:MANDIRA
Middle Name:N
Last Name:MEHRA
Suffix:
Gender:F
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:PO BOX 7219
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-7219
Mailing Address - Country:US
Mailing Address - Phone:703-655-4387
Mailing Address - Fax:703-655-4387
Practice Address - Street 1:4437 BROOKFIELD CORPORATE DR STE 109
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2122
Practice Address - Country:US
Practice Address - Phone:703-655-4387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64488-20208VP0000X
VA0101256018208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400244989Medicare PIN