Provider Demographics
NPI:1578856662
Name:MANFREDI, BRIAN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JOHN
Last Name:MANFREDI
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:PO BOX 985
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0985
Mailing Address - Country:US
Mailing Address - Phone:518-793-1000
Mailing Address - Fax:518-793-1976
Practice Address - Street 1:170 CAREY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-7830
Practice Address - Country:US
Practice Address - Phone:518-793-1000
Practice Address - Fax:518-793-1976
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2881222085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology