Provider Demographics
NPI:1154409019
Name:MANTELL, BARRY ELLIS (MD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:ELLIS
Last Name:MANTELL
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 1:420 W SANTA ELENA RD
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-2926
Mailing Address - Country:US
Mailing Address - Phone:760-464-3892
Mailing Address - Fax:760-323-7259
Practice Address - Street 1:420 W SANTA ELENA RD
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-2926
Practice Address - Country:US
Practice Address - Phone:760-464-3892
Practice Address - Fax:760-323-7259
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG409772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48416Medicare UPIN
CA00G409771Medicare PIN
CAAO738ZMedicare PIN