Provider Demographics
NPI:1285732123
Name:MANYAM, LASMI (MD)
Entity type:Individual
Prefix:DR
First Name:LASMI
Middle Name:
Last Name:MANYAM
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 1:28244 QUEENS CT
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-4207
Mailing Address - Country:US
Mailing Address - Phone:248-255-8986
Mailing Address - Fax:
Practice Address - Street 1:28111 HOOVER RD
Practice Address - Street 2:SUITE 7A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4153
Practice Address - Country:US
Practice Address - Phone:586-751-1500
Practice Address - Fax:586-573-0902
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB43434Medicare UPIN