Provider Demographics
NPI:1023086873
Name:MANCHANDIA, MANOHAR R (MD)
Entity type:Individual
Prefix:
First Name:MANOHAR
Middle Name:R
Last Name:MANCHANDIA
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 1:2706 SHED RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3348
Mailing Address - Country:US
Mailing Address - Phone:318-747-5272
Mailing Address - Fax:318-746-9669
Practice Address - Street 1:2706 SHED RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3348
Practice Address - Country:US
Practice Address - Phone:318-747-5272
Practice Address - Fax:318-746-9669
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05497R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1314056Medicaid
LA1314056Medicaid