Provider Demographics
NPI:1104123017
Name:MANCHINENI, LAKSHMI PAVAN (MD)
Entity type:Individual
Prefix:
First Name:LAKSHMI PAVAN
Middle Name:
Last Name:MANCHINENI
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 1:1350 N CAPITOL AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2521
Mailing Address - Country:US
Mailing Address - Phone:914-414-6159
Mailing Address - Fax:
Practice Address - Street 1:119 BELMONT ST
Practice Address - Street 2:HOSPITAL MEDICINE
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2903
Practice Address - Country:US
Practice Address - Phone:508-334-8515
Practice Address - Fax:508-334-6490
Is Sole Proprietor?:No
Enumeration Date:2011-02-13
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247038207R00000X
CAC144266208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA002268401Medicare PIN