Provider Demographics
NPI:1174618672
Name:MANDYAM, VIJAY (DPM)
Entity type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:
Last Name:MANDYAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43713 20TH ST W STE 5
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4628
Mailing Address - Country:US
Mailing Address - Phone:661-945-8700
Mailing Address - Fax:661-945-8757
Practice Address - Street 1:43713 20TH ST W STE 5
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4628
Practice Address - Country:US
Practice Address - Phone:661-945-8700
Practice Address - Fax:661-945-8757
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4071213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E40711Medicaid
CAU67472Medicare UPIN
CA5033870001Medicare NSC
CAE4071AMedicare ID - Type UnspecifiedMEDICARE NUMBER