Provider Demographics
NPI:1063578060
Name:MANCHANDA, PREM (MD)
Entity type:Individual
Prefix:DR
First Name:PREM
Middle Name:
Last Name:MANCHANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:SUIYE 220
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-910-3484
Mailing Address - Fax:804-414-7762
Practice Address - Street 1:4100 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-1021
Practice Address - Country:US
Practice Address - Phone:703-981-4865
Practice Address - Fax:804-414-7762
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD54095207R00000X
VA0101057630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG35572Medicare UPIN
MD010324M92Medicare ID - Type Unspecified