Provider Demographics
NPI:1790878783
Name:MANTHENA, ANJI R (MD)
Entity Type:Individual
Prefix:
First Name:ANJI
Middle Name:R
Last Name:MANTHENA
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 1:1906 RAY SHELL CT
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:TX
Mailing Address - Zip Code:77586-4585
Mailing Address - Country:US
Mailing Address - Phone:281-291-8226
Mailing Address - Fax:
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4220
Practice Address - Country:US
Practice Address - Phone:281-332-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0631174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097466901Medicaid
TX86J493Medicare ID - Type Unspecified
TX097466901Medicaid