Healthcare Provider Details

I. General information

NPI: 1730170655
Provider Name (Legal Business Name): NARAIN D MANDHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/11/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER DR
MONTICELLO IL
61856-2116
US

IV. Provider business mailing address

1000 MEDICAL CENTER DR
MONTICELLO IL
61856-2116
US

V. Phone/Fax

Practice location:
  • Phone: 217-762-6241
  • Fax: 217-762-1702
Mailing address:
  • Phone: 217-762-1701
  • Fax: 217-762-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036091129
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number036091129
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-091129
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: