Provider Demographics
NPI:1104050772
Name:MANTHE, MEGAN JANE (MD)
Entity type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:JANE
Last Name:MANTHE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 E RIVER BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8807
Mailing Address - Country:US
Mailing Address - Phone:417-820-5610
Mailing Address - Fax:
Practice Address - Street 1:3050 E RIVER BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-8807
Practice Address - Country:US
Practice Address - Phone:417-820-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA072978207X00000X
FLME119478207X00000X
MOPENDING207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012721100Medicaid
FLHX454XMedicare PIN