Provider Demographics
NPI:1184738585
Name:MANN, WILLARD KENNETH JR (DDS, MD)
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:KENNETH
Last Name:MANN
Suffix:JR
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 PRYTANIA STREET
Mailing Address - Street 2:PMB235
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-4221
Mailing Address - Country:US
Mailing Address - Phone:504-867-2200
Mailing Address - Fax:800-619-0163
Practice Address - Street 1:5500 PRYTANIA ST # 235
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-4221
Practice Address - Country:US
Practice Address - Phone:504-867-2200
Practice Address - Fax:800-619-0163
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018257208600000X
LAMD.018257207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1367575Medicaid
MS03328769Medicaid
LA1367575Medicaid
LA438117YH3UMedicare PIN
LA5L988Medicare PIN