Provider Demographics
NPI:1417948712
Name:MANDAVILLI, BELA S (MD)
Entity Type:Individual
Prefix:DR
First Name:BELA
Middle Name:S
Last Name:MANDAVILLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BELA
Other - Middle Name:P
Other - Last Name:DESAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41 BREWSTER RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5161
Mailing Address - Country:US
Mailing Address - Phone:860-585-3591
Mailing Address - Fax:
Practice Address - Street 1:111 FOUNDERS PLZ
Practice Address - Street 2:#300 C/O IPMS
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3212
Practice Address - Country:US
Practice Address - Phone:860-282-4137
Practice Address - Fax:860-282-0170
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037000207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001370006Medicaid