Basic Information
| Provider Information | |||||||||
| NPI: | 1174730071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANSFIELD | ||||||||
| FirstName: | MYCAL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602666013 | ||||||||
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| Practice Location | |||||||||
| Address1: | 104 NICHOLAS PL | ||||||||
| Address2: | |||||||||
| City: | AVILLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467100069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2608973308 | ||||||||
| FaxNumber: | 2608973650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01067081A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000656884 | 01 | IN | ANTHEM | OTHER | 200950300 | 05 | IN | MEDICAID |