Provider Demographics
NPI:1801829676
Name:MANOV, ANDRE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:
Last Name:MANOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANDREY
Other - Middle Name:
Other - Last Name:MANOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 100744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2880 N TENAYA WAY STE 400
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0642
Practice Address - Country:US
Practice Address - Phone:702-962-9550
Practice Address - Fax:702-962-5536
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2239207R00000X, 207RE0101X
NV19604207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104507208Medicaid
TX104507204Medicaid