Provider Demographics
NPI:1184957102
Name:MANDARANO, MICHAEL ANTHONY (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:MANDARANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1141 CLAY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-1191
Mailing Address - Country:US
Mailing Address - Phone:570-343-1722
Mailing Address - Fax:570-343-7110
Practice Address - Street 1:1141 CLAY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-1191
Practice Address - Country:US
Practice Address - Phone:570-343-1722
Practice Address - Fax:570-343-7110
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015862207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026658790002Medicaid
PA231569YGDBMedicare PIN