Provider Demographics
NPI:1548764160
Name:MANN, DAVID REZIN
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:REZIN
Last Name:MANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 LAKE CREST DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-3819
Mailing Address - Country:US
Mailing Address - Phone:801-494-4850
Mailing Address - Fax:
Practice Address - Street 1:96 JONATHAN LUCAS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-6077
Practice Address - Country:US
Practice Address - Phone:843-693-8908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL82296390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program