Provider Demographics
NPI:1679611198
Name:MANDALOS, GEORGE ELIAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ELIAS
Last Name:MANDALOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:19 SAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042
Mailing Address - Country:US
Mailing Address - Phone:860-643-8312
Mailing Address - Fax:860-432-5660
Practice Address - Street 1:100 RETREAT AV
Practice Address - Street 2:SUITE 612
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-997-8410
Practice Address - Fax:860-432-5660
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT172902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
B83895Medicare UPIN