Provider Demographics
NPI:1376904417
Name:MANDAL'S CONSERVATIVE NEPHROLOGY PRACTICE, LLC
Entity Type:Organization
Organization Name:MANDAL'S CONSERVATIVE NEPHROLOGY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANIL
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:MANDAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-305-1234
Mailing Address - Street 1:800 ZEAGLER DR
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 ZEAGLER DR
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3883
Practice Address - Country:US
Practice Address - Phone:904-824-8158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0074439207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255413500Medicaid
FL255413500Medicaid