Healthcare Provider Details

I. General information

NPI: 1811988868
Provider Name (Legal Business Name): NICHOLAS J MANDALAKAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 S STATE ST STE 100
DOVER DE
19901-4112
US

IV. Provider business mailing address

1113 S STATE ST STE 100
DOVER DE
19901-4112
US

V. Phone/Fax

Practice location:
  • Phone: 302-734-7676
  • Fax: 302-734-7615
Mailing address:
  • Phone: 302-734-7676
  • Fax: 302-734-7615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC1-0024586
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD037192E
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberMD037192E
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberC1-0024586
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: