Provider Demographics
NPI:1477551869
Name:MANDAVA, SURESH (MD)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:
Last Name:MANDAVA
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 1:2046 W MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4523
Mailing Address - Country:US
Mailing Address - Phone:203-869-3082
Mailing Address - Fax:203-869-6453
Practice Address - Street 1:2046 W MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-4523
Practice Address - Country:US
Practice Address - Phone:203-869-3082
Practice Address - Fax:203-869-6453
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036932207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
010036932CT01OtherANTHEM BCBS
2046779OtherAETNA
036932OtherCONNECTICARE
2V8862OtherHEALTHNET
9Y214OtherEMPIRE
2046779OtherAETNA
G73816Medicare UPIN
9Y214OtherEMPIRE