Provider Demographics
NPI:1861681231
Name:RAI, MANDEEP K (MD)
Entity Type:Individual
Prefix:
First Name:MANDEEP
Middle Name:K
Last Name:RAI
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 1:4531 N 16TH ST STE 114
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5344
Mailing Address - Country:US
Mailing Address - Phone:602-274-0078
Mailing Address - Fax:602-266-4477
Practice Address - Street 1:5555 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4622
Practice Address - Country:US
Practice Address - Phone:602-865-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27036207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ522533Medicaid
AZP00251398OtherRR MEDICARE
AZ522533Medicaid
AZZ104261Medicare PIN