Basic Information
| Provider Information | |||||||||
| NPI: | 1073501821 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANDAVA | ||||||||
| FirstName: | VASUDEVARAO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 E 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CENTER LINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480151167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866199986 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18 MARKET ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867832222 | ||||||||
| FaxNumber: | 5867836280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | VM031566 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1096276 | 05 | MI | MEDICAID |