Healthcare Provider Details

I. General information

NPI: 1932309291
Provider Name (Legal Business Name): SANGEETA MANDAPAKA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE STE 101
CHARLESTON WV
25304-1215
US

IV. Provider business mailing address

3200 MACCORKLE AVENUE SE OUTPATIENT CARE CLINIC
CHARLESTON WV
25304
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-8200
  • Fax: 304-388-7010
Mailing address:
  • Phone: 304-388-5590
  • Fax: 304-388-8238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number24019
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number24019
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: