Provider Demographics
NPI:1457346546
Name:MANDI, DENISE M (DPM)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:MANDI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:M
Other - Last Name:MANDRACCHIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1801 HICKMAN ROAD
Mailing Address - Street 2:BROADLAWNS MEDICAL CENTER
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1975
Mailing Address - Country:US
Mailing Address - Phone:515-282-2200
Mailing Address - Fax:515-282-3234
Practice Address - Street 1:1801 HICKMAN ROAD
Practice Address - Street 2:BROADLAWNS MEDICAL CENTER
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1975
Practice Address - Country:US
Practice Address - Phone:515-282-2200
Practice Address - Fax:515-282-3234
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00779213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0446112Medicaid
IAI13062Medicare ID - Type Unspecified
IAV01183Medicare UPIN