Provider Demographics
NPI:1821358003
Name:PAKKALA, MANJIT (MD)
Entity Type:Individual
Prefix:
First Name:MANJIT
Middle Name:
Last Name:PAKKALA
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 1:5325 FARAON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3488
Mailing Address - Country:US
Mailing Address - Phone:816-271-6406
Mailing Address - Fax:816-271-6789
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:404-367-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015021659207R00000X, 208M00000X
GA005442207R00000X
KS0439088207R00000X
GA73446208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201125270AMedicaid
MOP01527145OtherRR MEDICARE
MO1821358003Medicaid
IA1821358003Medicaid
MO1821358003Medicaid