Provider Demographics
NPI:1811952237
Name:MANYAM, BOSE (MD)
Entity type:Individual
Prefix:DR
First Name:BOSE
Middle Name:
Last Name:MANYAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E OAK AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4163
Mailing Address - Country:US
Mailing Address - Phone:870-268-4404
Mailing Address - Fax:870-268-4478
Practice Address - Street 1:201 E OAK AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4163
Practice Address - Country:US
Practice Address - Phone:870-268-4404
Practice Address - Fax:870-268-4478
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-11902207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR231587001Medicaid
FL31976OtherBLUE CROSS/BLUE SHIELD
FL060043440OtherRAILROAD MEDICARE
FL31976ZMedicare PIN