Provider Demographics
NPI:1356683957
Name:MANDEVILLE, BRIAN W JR (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:MANDEVILLE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2215 LANDOVER PL
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2115
Mailing Address - Country:US
Mailing Address - Phone:434-947-3944
Mailing Address - Fax:866-617-8273
Practice Address - Street 1:2215 LANDOVER PL
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2115
Practice Address - Country:US
Practice Address - Phone:434-947-3944
Practice Address - Fax:866-617-8273
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101239244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1356683957Medicaid
VA1356683957Medicaid