Healthcare Provider Details

I. General information

NPI: 1457766123
Provider Name (Legal Business Name): CHETAN MANDELIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2014
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 HERBERT CT
GREENVILLE NC
27834-3736
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-4963
  • Fax: 252-744-1514
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.130111
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number2020-00462
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: