Provider Demographics
NPI:1881007268
Name:MANDIMIKA, CHARISSE LAURA (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARISSE
Middle Name:LAURA
Last Name:MANDIMIKA
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 1:1450 CHAPEL ST # PRIVATE3
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4405
Mailing Address - Country:US
Mailing Address - Phone:203-789-4044
Mailing Address - Fax:
Practice Address - Street 1:15 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3221
Practice Address - Country:US
Practice Address - Phone:203-688-5303
Practice Address - Fax:203-688-3216
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2015-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program