Provider Demographics
NPI:1174689335
Name:MANDEGAR, MEHRAN (MD)
Entity Type:Individual
Prefix:
First Name:MEHRAN
Middle Name:
Last Name:MANDEGAR
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 26940
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92196-0940
Mailing Address - Country:US
Mailing Address - Phone:888-664-8297
Mailing Address - Fax:801-650-6861
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:888-664-8297
Practice Address - Fax:801-650-6861
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63770207RC0200X, 207RP1001X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1911036Medicaid
CA1911036Medicaid
CAH66917Medicare UPIN