Healthcare Provider Details

I. General information

NPI: 1023086873
Provider Name (Legal Business Name): MANOHAR R. MANCHANDIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2706 SHED RD
BOSSIER CITY LA
71111-3348
US

IV. Provider business mailing address

2706 SHED RD
BOSSIER CITY LA
71111-3348
US

V. Phone/Fax

Practice location:
  • Phone: 318-747-5272
  • Fax: 318-746-9669
Mailing address:
  • Phone: 318-747-5272
  • Fax: 318-746-9669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number05497R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: