Provider Demographics
NPI:1326152125
Name:DIAS-MANDOLY, PHILLIP C (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:C
Last Name:DIAS-MANDOLY
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 1:111 HAZEL LANE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-1253
Mailing Address - Country:US
Mailing Address - Phone:412-749-7330
Mailing Address - Fax:412-749-6763
Practice Address - Street 1:111 HAZEL LANE
Practice Address - Street 2:SUITE 300
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-1253
Practice Address - Country:US
Practice Address - Phone:412-749-7330
Practice Address - Fax:412-749-6763
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040982E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01653816Medicaid
PA0016538160002Medicaid
PA606906GZUMedicare PIN
PAE55555Medicare UPIN
PAE5555Medicare UPIN
PADI606906Medicare ID - Type Unspecified