MEDICARE: KATHLEEN ANNE MANNAVA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZD0900X	Dermatopathology (Pathology) Physician	289437	NY
2	207N00000X	Dermatology Physician	289437	NY

General Provider Information

NPI Number	:	1427284488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN ANNE MANNAVA M.D.

Provider Business Mailing Address
First Line	:	601 ELMWOOD AVE BOX 697
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14642-0001
Country	:	US
Telephone Number	:	585-275-7546
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 RED CREEK DR STE 200
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14623-4281
Country	:	US
Telephone Number	:	585-487-1400
Fax Number	:	585-487-1188

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2009
Last Update Date	:	06/29/2023

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