Provider Demographics
NPI:1174730071
Name:MANSFIELD, MYCAL L (MD)
Entity type:Individual
Prefix:
First Name:MYCAL
Middle Name:L
Last Name:MANSFIELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:
Practice Address - Street 1:104 NICHOLAS PL
Practice Address - Street 2:
Practice Address - City:AVILLA
Practice Address - State:IN
Practice Address - Zip Code:46710-0069
Practice Address - Country:US
Practice Address - Phone:260-897-3308
Practice Address - Fax:260-897-3650
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067081A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000656884OtherANTHEM
IN200950300Medicaid
IN048580P5Medicare PIN
IN000000656884OtherANTHEM
INM400020207Medicare PIN