Healthcare Provider Details

I. General information

NPI: 1629519038
Provider Name (Legal Business Name): GREGORY MANDILE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8130 LAKEWOOD MAIN ST STE 103
LAKEWOOD RANCH FL
34202-5068
US

IV. Provider business mailing address

2413 LAKEWOOD RANCH BLVD N
LAKEWOOD RANCH FL
34240-7025
US

V. Phone/Fax

Practice location:
  • Phone: 941-499-2700
  • Fax: 941-487-0474
Mailing address:
  • Phone: 941-499-2700
  • Fax: 941-487-0474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS16535
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS16535
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: