Provider Demographics
NPI:1326016460
Name:MANDVIWALA, AQEEL H (MD)
Entity Type:Individual
Prefix:
First Name:AQEEL
Middle Name:H
Last Name:MANDVIWALA
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 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7840
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:1210 W 5TH ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2112
Practice Address - Country:US
Practice Address - Phone:606-864-4030
Practice Address - Fax:606-864-0115
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31400207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64314016Medicaid
0965502Medicare ID - Type Unspecified
0784001Medicare ID - Type Unspecified
0768602Medicare ID - Type Unspecified
0930804Medicare ID - Type Unspecified
0305808Medicare ID - Type Unspecified
G26697Medicare UPIN
KY64314016Medicaid