Provider Demographics
NPI:1366538753
Name:MANDAVA, ASHA (MD)
Entity type:Individual
Prefix:
First Name:ASHA
Middle Name:
Last Name:MANDAVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 841969
Mailing Address - Street 2:UNIVERSITY OF ILLINOIS MEDICAL CENTER
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7232
Mailing Address - Country:US
Mailing Address - Phone:832-824-2999
Mailing Address - Fax:
Practice Address - Street 1:11811 FM 1960 RD W
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-3827
Practice Address - Country:US
Practice Address - Phone:281-970-2337
Practice Address - Fax:281-970-2318
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXQ6768208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G94010Medicare UPIN