Provider Demographics
NPI:1720188717
Name:MANNEM, KOTI R (MD)
Entity Type:Individual
Prefix:DR
First Name:KOTI
Middle Name:R
Last Name:MANNEM
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 1:3150 GERSHWIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5859
Mailing Address - Country:US
Mailing Address - Phone:920-391-4700
Mailing Address - Fax:920-391-4870
Practice Address - Street 1:3150 GERSHWIN DRIVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5859
Practice Address - Country:US
Practice Address - Phone:920-391-4700
Practice Address - Fax:920-391-4870
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI240012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720188717Medicaid
WI1720188717Medicaid
WI700815Medicare ID - Type Unspecified