Provider Demographics
NPI:1013164854
Name:MANCHANDANI, NANIK R (MD)
Entity Type:Individual
Prefix:
First Name:NANIK
Middle Name:R
Last Name:MANCHANDANI
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 1:955 CONEY ISLAND AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1400
Mailing Address - Country:US
Mailing Address - Phone:347-475-2801
Mailing Address - Fax:
Practice Address - Street 1:2457 E MAIN ST UNIT 105
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-2685
Practice Address - Country:US
Practice Address - Phone:347-475-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-23
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28927207Q00000X
CT051039208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1013164854Medicaid
CT1013164854Medicaid
CTD400089979Medicare PIN