Provider Demographics
NPI:1033124995
Name:MANOHARAN, EDAKANDYIL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDAKANDYIL
Middle Name:
Last Name:MANOHARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:1980 HOLTON AVE E
Practice Address - Street 2:SUITE 301
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3366
Practice Address - Country:US
Practice Address - Phone:276-523-0390
Practice Address - Fax:276-523-5514
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA01011022988207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00W076W01Medicare PIN
TNB06714Medicare UPIN
VAP00205143Medicare PIN