Provider Demographics
NPI:1700980927
Name:MANFREDI, LON PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:PHILIP
Last Name:MANFREDI
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 1:388 WEST CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040
Mailing Address - Country:US
Mailing Address - Phone:860-649-1120
Mailing Address - Fax:860-645-8541
Practice Address - Street 1:388 WEST CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040
Practice Address - Country:US
Practice Address - Phone:860-649-1120
Practice Address - Fax:860-645-8541
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031483207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001314830Medicaid
160001618Medicare PIN
CT001314830Medicaid