Provider Demographics
NPI:1710326418
Name:MANDIA, JEREMY JOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JOEL
Last Name:MANDIA
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 1:8312 N BROOK LN
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-2613
Mailing Address - Country:US
Mailing Address - Phone:845-702-7358
Mailing Address - Fax:
Practice Address - Street 1:841 S CLOVERDALE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4818
Practice Address - Country:US
Practice Address - Phone:310-921-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY279197208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program