Healthcare Provider Details

I. General information

NPI: 1841726148
Provider Name (Legal Business Name): AUSTIN MANDOYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 NATIONAL AVE
SAN DIEGO CA
92113-2113
US

IV. Provider business mailing address

9518 MISSION GORGE RD PO BOX 710385
SANTEE CA
92072-7001
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD.MD.70158229
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA161682
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD232283
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: