Provider Demographics
NPI:1528212511
Name:MANDIGO, GRACE KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:KIM
Last Name:MANDIGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E 77TH ST APT 6A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-2451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 W 168TH ST FL 4
Practice Address - Street 2:NEUROLOGICAL INSTITUTE, DEPARTMENT OF NEUROSURGERY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3726
Practice Address - Country:US
Practice Address - Phone:212-305-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246538-1207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery