Provider Demographics
NPI:1477535540
Name:NISSANKA, MANAGE (MD)
Entity Type:Individual
Prefix:DR
First Name:MANAGE
Middle Name:
Last Name:NISSANKA
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 1:127 ROSEMARY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-1563
Mailing Address - Country:US
Mailing Address - Phone:860-916-2578
Mailing Address - Fax:
Practice Address - Street 1:127 ROSEMARY LN
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-1563
Practice Address - Country:US
Practice Address - Phone:860-916-2578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0165392084P0800X
FLME1350312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001165398Medicaid
CTB84234Medicare UPIN
CT001165398Medicaid