Provider Demographics
NPI:1447212279
Name:MANDERSON, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:MANDERSON
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 1:13 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-4121
Mailing Address - Country:US
Mailing Address - Phone:806-322-1333
Mailing Address - Fax:806-322-1334
Practice Address - Street 1:13 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4121
Practice Address - Country:US
Practice Address - Phone:806-322-1333
Practice Address - Fax:806-322-1334
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5614207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH94688Medicare UPIN
TX5724320001Medicare NSC
TX8F2787Medicare PIN