Provider Demographics
NPI:1164630679
Name:MANDA, SUDHIR (MD)
Entity Type:Individual
Prefix:
First Name:SUDHIR
Middle Name:
Last Name:MANDA
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:PO BOX 910221 STE # 350
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-0001
Mailing Address - Country:US
Mailing Address - Phone:520-519-7700
Mailing Address - Fax:
Practice Address - Street 1:603 N WILMOT RD
Practice Address - Street 2:STE. # 151
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2701
Practice Address - Country:US
Practice Address - Phone:520-886-0206
Practice Address - Fax:520-886-0829
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHRT2294207RH0003X
AZ50809207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ50809OtherAZ LICENSE
OH2855629Medicaid
AZZ179807Medicare PIN
OH7388751Medicare PIN