Provider Demographics
NPI:1063152189
Name:MANDZY, KYJ ROMAN (DO)
Entity type:Individual
Prefix:
First Name:KYJ
Middle Name:ROMAN
Last Name:MANDZY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8812 WOODED TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-4053
Mailing Address - Country:US
Mailing Address - Phone:502-491-5234
Mailing Address - Fax:
Practice Address - Street 1:502 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4720
Practice Address - Country:US
Practice Address - Phone:352-726-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program