Provider Demographics
NPI:1932309291
Name:MANDAPAKA, SANGEETA (MD)
Entity Type:Individual
Prefix:
First Name:SANGEETA
Middle Name:
Last Name:MANDAPAKA
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 1:3200 MACCORKLE AVENUE SE
Mailing Address - Street 2:OUTPATIENT CARE CLINIC
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-388-5590
Mailing Address - Fax:304-388-8238
Practice Address - Street 1:3100 MACCORKLE AVE SE STE 101
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1215
Practice Address - Country:US
Practice Address - Phone:304-388-8200
Practice Address - Fax:304-388-7010
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24019207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810017834Medicaid
WVP01108428OtherRAILROAD MEDICAR
WV3810017834Medicaid