Provider Demographics
NPI:1982812392
Name:ANDERSON, MANDY MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MANDY
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MANDY
Other - Middle Name:MARIE
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 600763
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-0763
Mailing Address - Country:US
Mailing Address - Phone:619-717-6667
Mailing Address - Fax:
Practice Address - Street 1:4077 FIFTH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-717-6667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7925207V00000X
TXBP10025285207V00000X
CAA113914207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology