Provider Demographics
NPI:1891932729
Name:MANDAVA, ANISHA (MD)
Entity type:Individual
Prefix:
First Name:ANISHA
Middle Name:
Last Name:MANDAVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MCWILLAMS DRIVE
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269
Mailing Address - Country:US
Mailing Address - Phone:770-702-1864
Mailing Address - Fax:833-305-0287
Practice Address - Street 1:100 MCWILLAMS DRIVE
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269
Practice Address - Country:US
Practice Address - Phone:770-702-1864
Practice Address - Fax:833-305-0287
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14458207RC0000X
NY250978208M00000X
CT047099208M00000X
GA95772207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
11939090OtherCAQH
P01198011OtherRAILROAD M'CARE
GK794YMedicare PIN
P01198011OtherRAILROAD M'CARE
NVV109508Medicare PIN
GK794XMedicare PIN