Provider Demographics
NPI:1114981818
Name:MANDAL, VANESSA JAIASHREE (MD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:JAIASHREE
Last Name:MANDAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DRIVE
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:916-379-2948
Mailing Address - Fax:916-858-7065
Practice Address - Street 1:2110 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-0000
Practice Address - Country:US
Practice Address - Phone:916-536-2500
Practice Address - Fax:281-545-1442
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM1435207R00000X
CAC55495207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178386201Medicaid
TX8G6218OtherBC/BS TX#
TXP00301395OtherRAILROAD GBA - RAILROAD MEDICARE
TXMD1435TXOtherWORKERS COMPENSATION
TX8G6218OtherBC/BS TX#
TXH42445Medicare UPIN