Provider Demographics
NPI:1174748404
Name:MANDEL, PHYLLIS KAREN (MD)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:KAREN
Last Name:MANDEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1060 E 100 S
Mailing Address - Street 2:SUITE L10
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1501
Mailing Address - Country:US
Mailing Address - Phone:801-328-1260
Mailing Address - Fax:801-350-4361
Practice Address - Street 1:1060 E 100 S
Practice Address - Street 2:SUITE L10
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1501
Practice Address - Country:US
Practice Address - Phone:801-328-1260
Practice Address - Fax:801-350-4361
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F77633Medicare UPIN
NY35N041Medicare ID - Type Unspecified