Provider Demographics
NPI:1548780844
Name:MILLS, MANDALYN J (DO)
Entity Type:Individual
Prefix:
First Name:MANDALYN
Middle Name:J
Last Name:MILLS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MANDALYN
Other - Middle Name:J
Other - Last Name:KAUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5301 FARAON ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3512
Mailing Address - Country:US
Mailing Address - Phone:816-271-1066
Mailing Address - Fax:816-271-6786
Practice Address - Street 1:802 N RIVERSIDE RD STE G50
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-2510
Practice Address - Country:US
Practice Address - Phone:816-671-4888
Practice Address - Fax:816-671-4890
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101023019208600000X
MO2022016390208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery