Provider Demographics
NPI:1104811694
Name:MANN, JOHN W III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:MANN
Suffix:III
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 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-230-8206
Practice Address - Fax:423-230-8502
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053656207R00000X
TN43439207R00000X, 208M00000X
VA0101254459207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100058980Medicaid
GA100001094CMedicaid
VA1104811694Medicaid
52484938OtherBCBSGA
TN1507594Medicaid
H92572Medicare UPIN
TN3002233Medicare PIN
VA1104811694Medicaid
TNP00640962Medicare PIN
GA100001094CMedicaid
TN10311I9744Medicare PIN
52484938OtherBCBSGA