Provider Demographics
NPI:1912129552
Name:MANDROLA, STACI A (MD)
Entity Type:Individual
Prefix:DR
First Name:STACI
Middle Name:A
Last Name:MANDROLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2220
Mailing Address - Country:US
Mailing Address - Phone:502-456-9738
Mailing Address - Fax:
Practice Address - Street 1:7504 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4108
Practice Address - Country:US
Practice Address - Phone:502-693-2681
Practice Address - Fax:502-456-9738
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41139207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000642419OtherANTHEM
KY3756448000OtherPASSPORT ADVANTAGE
KY7100094260Medicaid
KY50026942OtherPASSPORT
KY000000642419OtherANTHEM
KY01163001Medicare PIN
KY7100094260Medicaid