Provider Demographics
NPI:1407830698
Name:MANDA, RAMANUJA R (MD FACC FCCP)
Entity Type:Individual
Prefix:DR
First Name:RAMANUJA
Middle Name:R
Last Name:MANDA
Suffix:
Gender:M
Credentials:MD FACC FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:STE 3060
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5082
Mailing Address - Country:US
Mailing Address - Phone:262-656-8271
Mailing Address - Fax:262-656-8255
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:STE 3060
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5082
Practice Address - Country:US
Practice Address - Phone:262-656-8271
Practice Address - Fax:262-656-8255
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27743207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1407830698Medicaid
WI30745100Medicaid
WI000232085Medicare PIN
WI30745100Medicaid
WI1407830698Medicaid