Provider Demographics
NPI:1427502079
Name:MANDEGAR MEDICAL CORP
Entity type:Organization
Organization Name:MANDEGAR MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MEHRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDEGAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-664-8297
Mailing Address - Street 1:PO BOX 26940
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92196-0940
Mailing Address - Country:US
Mailing Address - Phone:888-664-8297
Mailing Address - Fax:801-650-6861
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:888-664-8297
Practice Address - Fax:801-650-6861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63770207RC0200X, 207RP1001X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1911036Medicaid
CA1911036Medicaid