Provider Demographics
NPI:1023018074
Name:MANICKAM, KANNAN (MD)
Entity Type:Individual
Prefix:
First Name:KANNAN
Middle Name:
Last Name:MANICKAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:25 CROSSROADS DR
Mailing Address - Street 2:STE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5421
Mailing Address - Country:US
Mailing Address - Phone:443-738-2889
Mailing Address - Fax:443-738-2713
Practice Address - Street 1:6820 HOSPITAL DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4352
Practice Address - Country:US
Practice Address - Phone:410-391-6131
Practice Address - Fax:410-391-6144
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2014-04-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01056563A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD731L /Medicare PIN