Healthcare Provider Details

I. General information

NPI: 1891905287
Provider Name (Legal Business Name): VIJAYSINHA MANDHARE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: VIJAY MANDHARE MD

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 WAKE FOREST RD STE 210
RALEIGH NC
27609-6864
US

IV. Provider business mailing address

3801 WAKE FOREST RD STE 210
RALEIGH NC
27609-6864
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-7246
  • Fax: 919-787-7247
Mailing address:
  • Phone: 919-787-7246
  • Fax: 919-787-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number2008-00275
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: