Provider Demographics
NPI:1649210485
Name:DAMANI, MANISH (MD)
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:
Last Name:DAMANI
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 1:1718 E 4TH ST
Mailing Address - Street 2:SUITE 807
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3260
Mailing Address - Country:US
Mailing Address - Phone:704-375-5755
Mailing Address - Fax:704-335-3380
Practice Address - Street 1:1718 E 4TH ST
Practice Address - Street 2:SUITE 807
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3260
Practice Address - Country:US
Practice Address - Phone:704-375-5755
Practice Address - Fax:704-335-3380
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100226174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH22035Medicare UPIN