Provider Demographics
NPI:1295716736
Name:MANDILAWI, SADIQ (MD)
Entity type:Individual
Prefix:MR
First Name:SADIQ
Middle Name:
Last Name:MANDILAWI
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 1:1234 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3329
Mailing Address - Country:US
Mailing Address - Phone:909-596-4879
Mailing Address - Fax:909-596-9199
Practice Address - Street 1:1234 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3329
Practice Address - Country:US
Practice Address - Phone:909-596-4879
Practice Address - Fax:909-596-9199
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34207207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A342070Medicaid
CACB220525OtherPTAN
CACB220525OtherPTAN
C35433Medicare UPIN