Provider Demographics
NPI:1134294796
Name:MANDAL, KATHRYN KOHELI (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:KOHELI
Last Name:MANDAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:KOHELI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9509 NORTH BEACH STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6399
Mailing Address - Country:US
Mailing Address - Phone:817-617-8650
Mailing Address - Fax:877-906-1852
Practice Address - Street 1:9509 NORTH BEACH STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6399
Practice Address - Country:US
Practice Address - Phone:817-617-8650
Practice Address - Fax:877-906-1852
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5344208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0046KVOtherBCBS GROUP
TX8K6668OtherBCBS
TX165592001Medicaid
17100066598OtherKELLER GROUP NPI