Provider Demographics
NPI:1083729941
Name:MANCHANDA, VIVEK K (MD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:K
Last Name:MANCHANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4122 KEATON CROSSING BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8218
Mailing Address - Country:US
Mailing Address - Phone:636-329-9077
Mailing Address - Fax:636-329-9076
Practice Address - Street 1:4122 KEATON CROSSING BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8218
Practice Address - Country:US
Practice Address - Phone:636-329-9077
Practice Address - Fax:636-329-9076
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2015-04-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2006017511207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE WEST
MOP01433382OtherRAILROAD MEDICARE PROVIDER PTAN
MO7233350001OtherNORIDIAN , MEDICARE DME
P00836305OtherRAILROAD MEDICARE
MO1083729941Medicaid
MO132300127Medicare PIN