Provider Demographics
NPI:1871677682
Name:MANDATO, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MANDATO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E DIXIE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7601
Mailing Address - Country:US
Mailing Address - Phone:352-787-5858
Mailing Address - Fax:
Practice Address - Street 1:910 OLD CAMP RD STE 120
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5605
Practice Address - Country:US
Practice Address - Phone:352-787-5858
Practice Address - Fax:352-728-6749
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1369212085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104390500Medicaid
NYRA2083Medicare PIN
NY02200388Medicaid