Provider Demographics
NPI:1306018767
Name:ROBERT S. MANDRESH DPM PC INC
Entity Type:Organization
Organization Name:ROBERT S. MANDRESH DPM PC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:MANDRESH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-313-1665
Mailing Address - Street 1:8330 NAAB RD STE 135
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1932
Mailing Address - Country:US
Mailing Address - Phone:317-415-6300
Mailing Address - Fax:317-415-6304
Practice Address - Street 1:8330 NAAB RD STE 135
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1932
Practice Address - Country:US
Practice Address - Phone:317-415-6300
Practice Address - Fax:317-415-6304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000552B213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1162650001Medicare NSC