Provider Demographics
NPI:1124012901
Name:MANDAL, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:MANDAL
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 1:25070 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1250
Mailing Address - Country:US
Mailing Address - Phone:847-585-7000
Mailing Address - Fax:847-240-0622
Practice Address - Street 1:1710 N RANDALL RD
Practice Address - Street 2:300
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9400
Practice Address - Country:US
Practice Address - Phone:847-931-0909
Practice Address - Fax:847-488-9596
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095612207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095612Medicaid
ILF96473Medicare UPIN
ILF400139516Medicare PIN
ILL59472Medicare ID - Type UnspecifiedMEDICARE-LOC 15
ILF400139516Medicare PIN