Provider Demographics
NPI:1982851028
Name:MANDAL, KAUSHIK (MD)
Entity type:Individual
Prefix:
First Name:KAUSHIK
Middle Name:
Last Name:MANDAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:2 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3236
Practice Address - Country:US
Practice Address - Phone:401-444-5891
Practice Address - Fax:401-444-8158
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01848208600000X
PAMD465533208G00000X
MDD71376208G00000X
MD248501208G00000X
MI4301500845208G00000X
RIMD20381208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD046489900Medicaid
NC1982851028Medicaid
NC179WXOtherBCBS NC
NCNCD7780322Medicare PIN
NC179WXOtherBCBS NC