Provider Demographics
NPI:1366784191
Name:MANDIGA, PALLAVI R (DO)
Entity type:Individual
Prefix:
First Name:PALLAVI
Middle Name:R
Last Name:MANDIGA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:PALLAVI
Other - Middle Name:RAO
Other - Last Name:MANDIGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:4845 KNIGHTSBRIDGE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-2463
Mailing Address - Country:US
Mailing Address - Phone:614-299-5838
Mailing Address - Fax:614-299-5929
Practice Address - Street 1:4845 KNIGHTSBRIDGE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-2463
Practice Address - Country:US
Practice Address - Phone:614-299-5838
Practice Address - Fax:614-299-5929
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34011955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine