Provider Demographics
NPI:1467429399
Name:MANFREDI, BRENDA L (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:L
Last Name:MANFREDI
Suffix:
Gender:F
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6316 OLD OAK RIDGE RD STE E
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-9940
Practice Address - Country:US
Practice Address - Phone:336-605-1337
Practice Address - Fax:336-605-3776
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.094392207Q00000X
CAG129943207Q00000X
NC2020-00427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3003654Medicaid
CT001378240Medicaid
CT080001323Medicare PIN
OH4279771Medicare PIN
G35088Medicare UPIN
OH3003654Medicaid