Provider Demographics
NPI:1609060466
Name:MANICKAM, BUVANA (MD)
Entity Type:Individual
Prefix:DR
First Name:BUVANA
Middle Name:
Last Name:MANICKAM
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 1:7500 FRANCE AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-3400
Mailing Address - Country:US
Mailing Address - Phone:952-835-1311
Mailing Address - Fax:612-863-1077
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:STE. 300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:613-333-8883
Practice Address - Fax:612-317-6686
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107177174400000X
IL036119261207R00000X
MN56982207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400098310Medicare PIN