Basic Information
| Provider Information | |||||||||
| NPI: | 1831333913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDAVA | ||||||||
| FirstName: | VEENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RATHOD | ||||||||
| OtherFirstName: | VEENA | ||||||||
| OtherMiddleName: | MANDAVA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 W CENTER STREET PROMENADE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928053960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144494841 | ||||||||
| FaxNumber: | 7149376233 | ||||||||
| Practice Location | |||||||||
| Address1: | 12602 AMARGOSA RD STE F | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923927640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605615000 | ||||||||
| FaxNumber: | 7609475619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2009 | ||||||||
| LastUpdateDate: | 04/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | MD60546513 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | A129908 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.