Provider Information for 1982364915
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MANDISHA MATTHEWS MARK
Sex: Female
NPI: 1982364915
Last Updated: 2021-12-17
Certification Date: 2021-11-23
Certification Date: 2021-11-23
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1982364915 | ||||||||
| Enumeration Date | 2021-12-17 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 513 VIA ALTOS MESQUITE, TX 75150-4426 United States Phone: 310-908-1233 | Fax: | ||||||||
| Primary Practice Address | 2306 GUTHRIE RD STE 260H GARLAND, TX 75043-5967 United States Phone: 469-290-3080 | Fax: | ||||||||
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