Provider Demographics
NPI:1700803525
Name:MANAS, KENNETH JAMES (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:MANAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF MEDICINE GASTROENTEROLOGY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2528
Mailing Address - Fax:318-813-2565
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF MEDICINE GASTROENTEROLOGY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-813-2528
Practice Address - Fax:318-813-2565
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA06583R207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1354848Medicaid
LA5L441F600Medicare ID - Type Unspecified
LA1354848Medicaid