MEDICARE: DR. KONOY MANDAL 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	2084P0800X	Psychiatry Physician	2002012686	MO
2	2084P0800X	Psychiatry Physician	DR.0050668	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518954866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KONOY MANDAL MD

Provider Business Mailing Address
First Line	:	1750 E KEN PRATT BLVD
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80504-5311
Country	:	US
Telephone Number	:	720-718-8310
Fax Number	:

Provider Business Practice Location Address
First Line	:	1750 E KEN PRATT BLVD
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80504-5311
Country	:	US
Telephone Number	:	720-718-8310
Fax Number	:

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

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	09/15/2020

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