Healthcare Provider Details

I. General information

NPI: 1639379209
Provider Name (Legal Business Name): RICHARD WILLIAM MANKINEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-842-3480
  • Fax:
Mailing address:
  • Phone: 504-842-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberLL30044
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD0000046071
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD.205289
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: