Provider Demographics
NPI:1811988868
Name:MANDALAKAS, NICHOLAS J (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:J
Last Name:MANDALAKAS
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 1:1113 S STATE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-4112
Mailing Address - Country:US
Mailing Address - Phone:302-734-7676
Mailing Address - Fax:302-734-7615
Practice Address - Street 1:1113 S STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4112
Practice Address - Country:US
Practice Address - Phone:302-734-7676
Practice Address - Fax:302-734-7615
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0024586207RC0000X, 207RC0001X
PAMD037192E207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012589910006Medicaid
593146GP6Medicare ID - Type Unspecified
E85169Medicare UPIN