Healthcare Provider Details

I. General information

NPI: 1194010595
Provider Name (Legal Business Name): PURNIMA MANDAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 SUNSET BLVD MAILSTOP #94
LOS ANGELES CA
90027
US

IV. Provider business mailing address

4650 SUNSET BLVD MAILSTOP #94
LOS ANGELES CA
90027
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-3677
  • Fax: 323-361-8106
Mailing address:
  • Phone: 323-361-3677
  • Fax: 323-361-8106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number261766
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: