Provider Demographics
NPI:1265423651
Name:MANOHAR, PRERANA ANAND (MD)
Entity type:Individual
Prefix:DR
First Name:PRERANA
Middle Name:ANAND
Last Name:MANOHAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5043 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3724
Mailing Address - Country:US
Mailing Address - Phone:616-719-5939
Mailing Address - Fax:616-719-5933
Practice Address - Street 1:5043 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3724
Practice Address - Country:US
Practice Address - Phone:616-719-5939
Practice Address - Fax:616-719-5933
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080691207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4713480Medicaid
MIOD17643037Medicare ID - Type Unspecified
MI4713480Medicaid