Provider Demographics
NPI:1831333913
Name:MANDAVA, VEENA (MD)
Entity type:Individual
Prefix:DR
First Name:VEENA
Middle Name:
Last Name:MANDAVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VEENA
Other - Middle Name:MANDAVA
Other - Last Name:RATHOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:200 W CENTER STREET PROMENADE STE 300
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:714-449-4841
Mailing Address - Fax:714-937-6233
Practice Address - Street 1:12602 AMARGOSA RD STE F
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-7640
Practice Address - Country:US
Practice Address - Phone:760-561-5000
Practice Address - Fax:760-947-5619
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD605465132085B0100X
CAA1299082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging