MEDICARE: ANNA M MANDALAKAS 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	2080P0006X	Developmental - Behavioral Pediatrics Physician	35-072385	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000183305	OTHER	OH	ANTHEM
2	2012575	OTHER	OH	BCMH
3	363801	OTHER	OH	WELLCARE
4	000000221080	OTHER		UNISON
5	000000526102	OTHER	OH	ANTHEM
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	2352239	OTHER	OH	AETNA

General Provider Information

NPI Number	:	1720006620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNA M MANDALAKAS MD

Provider Business Mailing Address
First Line	:	24701 EUCLID AVE
Second Line	:	3RD FLOOR
City	:	EUCLID
State	:	OH
Zip	:	44117-1714
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11100 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-1716
Country	:	US
Telephone Number	:	216-844-7700
Fax Number	:

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/20/2011

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