Provider Demographics
NPI:1659384980
Name:MANDA, WINFRED C (MD)
Entity Type:Individual
Prefix:
First Name:WINFRED
Middle Name:C
Last Name:MANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 MACKEY BRANCH DR
Mailing Address - Street 2:STE #101
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3482
Mailing Address - Country:US
Mailing Address - Phone:423-553-1155
Mailing Address - Fax:423-553-1124
Practice Address - Street 1:1350 MACKEY BRANCH DR
Practice Address - Street 2:STE # 101
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3482
Practice Address - Country:US
Practice Address - Phone:423-553-1155
Practice Address - Fax:423-553-1124
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN38183207RP1001X
TN038183207RS0012X, 207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN0101Medicaid
H75007Medicare UPIN
TN3889651Medicare ID - Type UnspecifiedINDIVIDUAL