Provider Demographics
NPI:1144232349
Name:MAHDYOON, MANI (MD)
Entity Type:Individual
Prefix:
First Name:MANI
Middle Name:
Last Name:MAHDYOON
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 1:845 S FAIRMONT AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5113
Mailing Address - Country:US
Mailing Address - Phone:209-366-2360
Mailing Address - Fax:209-366-2352
Practice Address - Street 1:845 S FAIRMONT AVE STE 5
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5113
Practice Address - Country:US
Practice Address - Phone:209-366-2360
Practice Address - Fax:209-366-2352
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65782207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A657820Medicaid
CA00A657823Medicare PIN
CA00A657820Medicaid