Healthcare Provider Details

I. General information

NPI: 1114970233
Provider Name (Legal Business Name): STUART B MANNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6655 E US HIGHWAY 36
AVON IN
46123-8923
US

IV. Provider business mailing address

5101 E US HIGHWAY 36 STE 100
AVON IN
46123-6646
US

V. Phone/Fax

Practice location:
  • Phone: 888-714-1927
  • Fax: 317-272-0807
Mailing address:
  • Phone: 888-714-1927
  • Fax: 317-272-0807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01032748
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: