=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215255179
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUGANYA MANIVANNAN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2010
-----------------------------------------------------
Last Update Date | 01/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 703 E MARSHALL AVE STE 5008
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-5557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-315-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 230 LEXINGTON GREEN CIR STE 600
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-971-4695
-----------------------------------------------------
Fax | 859-971-4604
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | U3935
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | U3935
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------