Provider Demographics
NPI:1982851028
Name:MANDAL, KAUSHIK (MD)
Entity Type:Individual
Prefix:
First Name:KAUSHIK
Middle Name:
Last Name:MANDAL
Suffix:
Gender:M
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:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:6001 W OUTER DR STE 300
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2626
Practice Address - Country:US
Practice Address - Phone:313-832-0650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01848208600000X
PAMD465533208G00000X
MDD71376208G00000X
MD248501208G00000X
MI4301500845208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1982851028Medicaid
MD046489900Medicaid
NC179WXOtherBCBS NC
NCNCD7780322Medicare PIN
NC179WXOtherBCBS NC