Provider Demographics
NPI:1285659672
Name:MANDICH, PAUL A (DC)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:MANDICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617-45TH STREET
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2902
Mailing Address - Country:US
Mailing Address - Phone:219-924-4456
Mailing Address - Fax:219-924-6342
Practice Address - Street 1:2617-45TH STREET
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2902
Practice Address - Country:US
Practice Address - Phone:219-924-4456
Practice Address - Fax:219-924-6342
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000721A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000090592OtherANTHEM BC/BS
IL90000622OtherBCBS OF ILLINOIS
IN409130Medicare ID - Type Unspecified
IN000000090592OtherANTHEM BC/BS