Provider Demographics
NPI:1477609568
Name:MANDAVA, BOSE (MD)
Entity Type:Individual
Prefix:
First Name:BOSE
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 1:3418 LOMA VISTA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003
Mailing Address - Country:US
Mailing Address - Phone:805-642-8565
Mailing Address - Fax:805-642-8564
Practice Address - Street 1:825 NORTH 10TH STREET
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060
Practice Address - Country:US
Practice Address - Phone:805-933-8600
Practice Address - Fax:805-933-8664
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC5112207L00000X
CAC51112207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C511120Medicaid
CA00C511120Medicaid