MEDICARE: ASHA MANDAVA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	Q6768	TX

General Provider Information

NPI Number	:	1366538753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHA MANDAVA MD

Provider Business Mailing Address
First Line	:	PO BOX 841969
Second Line	:	UNIVERSITY OF ILLINOIS MEDICAL CENTER
City	:	DALLAS
State	:	TX
Zip	:	75284-7232
Country	:	US
Telephone Number	:	832-824-2999
Fax Number	:

Provider Business Practice Location Address
First Line	:	11811 FM 1960 RD W
Second Line	:	SUITE 100
City	:	HOUSTON
State	:	TX
Zip	:	77065-3827
Country	:	US
Telephone Number	:	281-970-2337
Fax Number	:	281-970-2318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	02/08/2017

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