Provider Demographics
NPI:1326145392
Name:PANDYA, MANISH (MD)
Entity Type:Individual
Prefix:DR
First Name:MANISH
Middle Name:
Last Name:PANDYA
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:PO BOX 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:
Practice Address - Street 1:301 S LAKE ST STE B
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-278-8575
Practice Address - Fax:505-787-2399
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0152207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1326145392Medicaid
AZ109497Medicaid
NM33633339Medicaid
CO04056558Medicaid
UT1326145392Medicaid
CO04056558Medicaid
P00322542Medicare PIN