Provider Demographics
NPI:1336377712
Name:MANCKE, BRIAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:MANCKE
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 1:2500 ENGLISH CREEK AVE.
Mailing Address - Street 2:BLDG 900 SUITE 909
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234
Mailing Address - Country:US
Mailing Address - Phone:609-407-2380
Mailing Address - Fax:609-677-7201
Practice Address - Street 1:1402 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227
Practice Address - Country:US
Practice Address - Phone:317-887-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD444818207Q00000X
OK29995207Q00000X
NJ25MA10978800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine