Provider Demographics
NPI:1831144013
Name:MANNAN, GHALIB (MD)
Entity Type:Individual
Prefix:
First Name:GHALIB
Middle Name:
Last Name:MANNAN
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 1:6029 WALNUT GROVE RD STE 209
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2112
Mailing Address - Country:US
Mailing Address - Phone:901-681-0778
Mailing Address - Fax:901-821-9987
Practice Address - Street 1:6029 WALNUT GROVE RD STE 209
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-681-0778
Practice Address - Fax:901-821-9987
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17199207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3865813Medicaid
TN3865814Medicaid
MS000124232Medicaid
MS00124232Medicaid