Provider Demographics
NPI:1841239902
Name:MANDZIJ, ROMAN W (DO)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:W
Last Name:MANDZIJ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WINNETKA AVE
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-4050
Mailing Address - Country:US
Mailing Address - Phone:847-501-4060
Mailing Address - Fax:847-501-4063
Practice Address - Street 1:525 WINNETKA AVE
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-4050
Practice Address - Country:US
Practice Address - Phone:847-501-4060
Practice Address - Fax:847-501-4063
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-096445207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G56653Medicare UPIN