Provider Demographics
NPI:1225369051
Name:MANDARO, STEPHEN LODOVICO (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:LODOVICO
Last Name:MANDARO
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 1:8139 SUNSET AVE
Mailing Address - Street 2:SUITE 242
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-5131
Mailing Address - Country:US
Mailing Address - Phone:916-209-8505
Mailing Address - Fax:916-967-1987
Practice Address - Street 1:8139 SUNSET AVE
Practice Address - Street 2:SUITE 242
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-5131
Practice Address - Country:US
Practice Address - Phone:916-209-8505
Practice Address - Fax:916-967-1987
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG503202083X0100X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7664031Medicaid
CA7664031Medicaid