Provider Demographics
NPI:1770523086
Name:MANDIGO, JAMES A III (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:MANDIGO
Suffix:III
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 1:1600 BOB WHITE DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-9304
Mailing Address - Country:US
Mailing Address - Phone:785-312-9561
Mailing Address - Fax:
Practice Address - Street 1:1112 W 6TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2215
Practice Address - Country:US
Practice Address - Phone:784-841-3211
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0429032174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSG72751Medicare UPIN
KS100610Medicare ID - Type Unspecified