Provider Demographics
NPI:1265461388
Name:MANNAN, MANISH (MD)
Entity type:Individual
Prefix:DR
First Name:MANISH
Middle Name:
Last Name:MANNAN
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:PO BOX 80158
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-0158
Mailing Address - Country:US
Mailing Address - Phone:317-660-2173
Mailing Address - Fax:317-660-2393
Practice Address - Street 1:8087 CASTLETON RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2053
Practice Address - Country:US
Practice Address - Phone:317-660-2173
Practice Address - Fax:317-660-2393
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062145A207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01062145AOtherINDIANA LICENSE
IN01062145BOtherCSR
BM9788906OtherDEA
IN01062145AOtherINDIANA LICENSE