1487654554 NPI number — DR. JOHN P MAMANA M.D.

Table of content: DR. JOHN P MAMANA M.D. (NPI 1487654554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487654554 NPI number — DR. JOHN P MAMANA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAMANA
Provider First Name:
JOHN
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAMANA
Provider Other First Name:
JOHN
Provider Other Middle Name:
PHILIP
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
SR.
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1487654554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12040 S LAKES DR
Provider Second Line Business Mailing Address:
SUITE205
Provider Business Mailing Address City Name:
RESTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20191-1246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-230-6990
Provider Business Mailing Address Fax Number:
703-230-0350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12040 S LAKES DR
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
RESTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20191-1246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-230-6990
Provider Business Practice Location Address Fax Number:
703-230-6990
Provider Enumeration Date:
07/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  0101021602 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 224013 . This is a "TRIGON KEYAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 257642 . This is a "MDIPA/OPTIMUM CHOICE/MAMS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5820308 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 461832 . This is a "AETNA/US HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 505114 . This is a "NCPPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 45560004 . This is a "BCBS DC CAPCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5325453-022 . This is a "CIGNA HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0400438 . This is a "UNITED HEALTH VIRGINIA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4092013 . This is a "AHP MGD CHOICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541908735 . This is a "PREFERRED PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 224013 . This is a "ANTHEM HEALTHKEEPERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 110184237 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 723576 . This is a "AFFORDABLE FIRST HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0403501 . This is a "UNITED HEALTH MID-ATLANTI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541908735 . This is a "CCN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541908735 . This is a "PHCS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 360386 . This is a "ONE HEALTH GREATWEST" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541908735 . This is a "CHAMPUS/TRICARE/STANDARD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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