MEDICARE: JYOTHI MANDAVA M.D.

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	2002002075	MO

General Provider Information

NPI Number	:	1891809539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JYOTHI MANDAVA M.D.

Provider Business Mailing Address
First Line	:	16091 SWINGLEY RIDGE RD STE 100
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63017-2056
Country	:	US
Telephone Number	:	636-778-1195
Fax Number	:	636-898-1019

Provider Business Practice Location Address
First Line	:	16091 SWINGLEY RIDGE RD STE 100
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63017-2056
Country	:	US
Telephone Number	:	636-778-1195
Fax Number	:	636-898-1019

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

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	08/16/2023

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