Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 01045232A | IN |
N | 208600000X | Surgeon | 01045232A | IN |
N | 2082S0105X | Plastic Hand Surgeon | 01045232A | IN |
Y | 2086S0122X | Plastic and Reconstructive Surgery | 01045232A | IN |
NPI | 1215020201 |
---|---|
Provider Name | Andrew Jay Mandery |
First Address | Indianapolis, IN 46290-1024 |
Second Address | Indianapolis, IN 46260-2006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 11/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00000093853 | BCBS (01) | |
200101450B | (05) | IN |
G28297 | (02) |