Healthcare Provider Details

I. General information

NPI: 1730144981
Provider Name (Legal Business Name): MANDEEP S. DHADLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE CARDIOLOGY DEPT
BOSTON MA
02215-3904
US

IV. Provider business mailing address

133 BROOKLINE AVE CARDIOLOGY DEPT
BOSTON MA
02215-3904
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-6050
  • Fax: 617-421-6083
Mailing address:
  • Phone: 617-421-6050
  • Fax: 617-421-6083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number81869
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number81869
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: