Provider Demographics
NPI:1710979117
Name:MANDY, GEORGE THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:THOMAS
Last Name:MANDY
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 1:555 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2654
Mailing Address - Country:US
Mailing Address - Phone:614-722-4559
Mailing Address - Fax:614-722-4541
Practice Address - Street 1:555 S 18TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2654
Practice Address - Country:US
Practice Address - Phone:614-722-4559
Practice Address - Fax:614-722-4541
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350836342080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64085855Medicaid
OH2321526Medicaid
KY64085855Medicaid
OHMA4130241Medicare ID - Type Unspecified