Provider Demographics
NPI:1265437354
Name:MANN, CHERYL A (MD)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:A
Last Name:MANN
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 1:805 E PIKE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:45334-0626
Mailing Address - Country:US
Mailing Address - Phone:937-596-0456
Mailing Address - Fax:937-596-0462
Practice Address - Street 1:805 E PIKE ST
Practice Address - Street 2:
Practice Address - City:JACKSON CENTER
Practice Address - State:OH
Practice Address - Zip Code:45334-0626
Practice Address - Country:US
Practice Address - Phone:937-596-0456
Practice Address - Fax:937-596-0462
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2020306Medicaid
OH010645905OtherTAX ID #
OH000000233110OtherANTHEM PIN #
OH080186052OtherRAILROAD MEDICARE
OH000000233110OtherANTHEM PIN #
OH2020306Medicaid