Provider Demographics
NPI:1467642900
Name:MANI MAHDYOON, M.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MANI MAHDYOON, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHDYOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-366-2360
Mailing Address - Street 1:845 S FAIRMONT AVE
Mailing Address - Street 2:SUITE #5
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5113
Mailing Address - Country:US
Mailing Address - Phone:209-366-2360
Mailing Address - Fax:209-366-2352
Practice Address - Street 1:845 S FAIRMONT AVE
Practice Address - Street 2:SUITE #5
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5113
Practice Address - Country:US
Practice Address - Phone:209-366-2360
Practice Address - Fax:209-366-2352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01998ZMedicare PIN