Healthcare Provider Details

I. General information

NPI: 1912468513
Provider Name (Legal Business Name): PERATHU KANNU RAKESH MANIVANNAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MORRIS STREET
CHARLESTON WV
25301
US

IV. Provider business mailing address

400 ASSOCIATION DRIVE SUITE 102
CHARLESTON WV
25311
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5432
  • Fax: 304-388-3604
Mailing address:
  • Phone: 304-760-7536
  • Fax: 304-760-7540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31337
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: