Provider Demographics
NPI:1386629822
Name:MANNAM, SUDHAKAR B (MD)
Entity Type:Individual
Prefix:
First Name:SUDHAKAR
Middle Name:B
Last Name:MANNAM
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 1:736 W INGOMAR RD UNIT 116
Mailing Address - Street 2:
Mailing Address - City:INGOMAR
Mailing Address - State:PA
Mailing Address - Zip Code:15127-6604
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:
Practice Address - Street 1:205 EASY ST STE 204
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-3128
Practice Address - Country:US
Practice Address - Phone:724-812-5580
Practice Address - Fax:201-812-5682
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426845207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101453513Medicaid
PA101453513Medicaid