Provider Demographics
NPI:1164413886
Name:MANDRYK, TED M (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:M
Last Name:MANDRYK
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3291 LOMA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3099
Mailing Address - Country:US
Mailing Address - Phone:805-652-6165
Mailing Address - Fax:
Practice Address - Street 1:3291 LOMA VISTA RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3099
Practice Address - Country:US
Practice Address - Phone:805-652-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64121207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G641210Medicaid
CAE88038Medicare UPIN
CAWG64121DMedicare PIN
CAWG64121EMedicare PIN