Provider Demographics
NPI:1821020041
Name:MANDEVILLE, LISA DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DAWN
Last Name:MANDEVILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2111
Mailing Address - Country:US
Mailing Address - Phone:404-299-9724
Mailing Address - Fax:404-299-0382
Practice Address - Street 1:315 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2111
Practice Address - Country:US
Practice Address - Phone:404-299-9724
Practice Address - Fax:404-299-0382
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046987207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2264676OtherAETNA/ USHC
GACN9240OtherGROUP RAILROAD MEDICARE
GA0700039OtherUNITED HEALTHCARE
GA000832851EMedicaid
GA160046634OtherRAILROAD MEDICARE
GA598968OtherBLUE CROSS BLUE SHIELD
GA7695077OtherAETNA/US HEALTHCARE
GA000832851DMedicaid
GA000832851EMedicaid
GA2264676OtherAETNA/ USHC