Provider Demographics
NPI:1770593006
Name:HAAS, MANDAL BRIAN (MD)
Entity type:Individual
Prefix:
First Name:MANDAL
Middle Name:BRIAN
Last Name:HAAS
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 1:1020 TRUMP RD NW
Mailing Address - Street 2:P.O. BOX 38
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615-8422
Mailing Address - Country:US
Mailing Address - Phone:330-739-5402
Mailing Address - Fax:330-627-7602
Practice Address - Street 1:1020 TRUMP RD NW
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615-8422
Practice Address - Country:US
Practice Address - Phone:330-627-7055
Practice Address - Fax:330-627-7602
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070993H207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2019916Medicaid
OH2019916Medicaid
OHHA0856611Medicare ID - Type Unspecified