Provider Demographics
NPI:1114452810
Name:PATEL, MANDIRA MANOJ (DO)
Entity Type:Individual
Prefix:
First Name:MANDIRA
Middle Name:MANOJ
Last Name:PATEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5085 CARTILLA AVE
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-1792
Mailing Address - Country:US
Mailing Address - Phone:909-560-5892
Mailing Address - Fax:
Practice Address - Street 1:21634 RETREAT PKWY
Practice Address - Street 2:
Practice Address - City:TEMESCAL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92883-6100
Practice Address - Country:US
Practice Address - Phone:951-493-6905
Practice Address - Fax:951-826-8120
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16797207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program