Basic Information
| Provider Information | |||||||||
| NPI: | 1841286002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDAVIA | ||||||||
| FirstName: | DIKU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51258 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900515558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109671884 | ||||||||
| FaxNumber: | 3109671744 | ||||||||
| Practice Location | |||||||||
| Address1: | 8700 BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900481804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109671884 | ||||||||
| FaxNumber: | 3109671744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G70785 | CA | X | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | G70785 | CA | X | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.