Provider Demographics
NPI:1639156342
Name:WAINSCOAT, MANDY A (DO)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:A
Last Name:WAINSCOAT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30 JORDAN LN
Mailing Address - Street 2:PRIME HEALTHCARE
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1278
Mailing Address - Country:US
Mailing Address - Phone:860-263-0253
Mailing Address - Fax:860-263-0262
Practice Address - Street 1:27 SYCAMORE ST
Practice Address - Street 2:STE 100, PRIME HEALTHCARE
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2223
Practice Address - Country:US
Practice Address - Phone:860-659-0581
Practice Address - Fax:860-652-3077
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT042898207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001428988Medicaid
CT040042898CT01OtherBCBS
CT042898OtherMEDICAL LICENSE
CT042898OtherMEDICAL LICENSE
CTBW9001051OtherDEA
I22646Medicare UPIN