Provider Demographics
NPI:1225252018
Name:MANDILE, GARY FREDERICK (CCP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:FREDERICK
Last Name:MANDILE
Suffix:
Gender:M
Credentials:CCP
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 27341
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-7341
Mailing Address - Country:US
Mailing Address - Phone:480-777-0607
Mailing Address - Fax:602-480-7771
Practice Address - Street 1:5801 S MCCLINTOCK DR
Practice Address - Street 2:SUITE 110
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-6002
Practice Address - Country:US
Practice Address - Phone:480-777-0607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist