Provider Demographics
NPI:1255393526
Name:MANDO, WAGIH R (MD)
Entity type:Individual
Prefix:DR
First Name:WAGIH
Middle Name:R
Last Name:MANDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 W ESPLANADE AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2489
Mailing Address - Country:US
Mailing Address - Phone:504-464-8619
Mailing Address - Fax:504-464-4876
Practice Address - Street 1:200 W ESPLANADE AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2489
Practice Address - Country:US
Practice Address - Phone:504-464-8619
Practice Address - Fax:504-464-4876
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA09630R208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1966312Medicaid
LAF54212Medicare UPIN
LA5G138Medicare PIN