Healthcare Provider Details

I. General information

NPI: 1902811656
Provider Name (Legal Business Name): CONRAD C MANAYAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 GEORGE BUSBEE PKWY NW STE 101
KENNESAW GA
30144
US

IV. Provider business mailing address

3820 NORTHDALE BLVD STE 201
TAMPA FL
33624-1893
US

V. Phone/Fax

Practice location:
  • Phone: 800-991-6117
  • Fax:
Mailing address:
  • Phone: 800-991-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1300
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0480
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number98137
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number98137
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: