Provider Demographics
NPI:1538143714
Name:MANDAVA, ANEEL (MD)
Entity Type:Individual
Prefix:
First Name:ANEEL
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 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:
Practice Address - Street 1:2801 K ST
Practice Address - Street 2:SUITE 502
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5120
Practice Address - Country:US
Practice Address - Phone:877-515-0053
Practice Address - Fax:916-454-6926
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA941752085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1538143714OtherMEDI-CAL
CA00A941750Medicaid
CA1538143714Medicaid
CA00A941750OtherBLUE SHIELD
CA1538143714OtherMEDI-CAL
CABH894WMedicare PIN
CA00A941751Medicare ID - Type UnspecifiedMEDICARE NUMBER
CA1538143714Medicaid
H92397Medicare UPIN