Provider Demographics
NPI:1629519038
Name:MANDILE, GREGORY (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MANDILE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 LAKEWOOD RANCH BLVD N
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34240-7025
Mailing Address - Country:US
Mailing Address - Phone:941-499-2700
Mailing Address - Fax:941-487-0474
Practice Address - Street 1:8130 LAKEWOOD MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-5068
Practice Address - Country:US
Practice Address - Phone:941-499-2700
Practice Address - Fax:941-487-0474
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16535208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty