Provider Demographics
NPI:1386739670
Name:MANN, DAVID A (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:MANN
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:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:3316 PATRIOT CT
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3782
Practice Address - Country:US
Practice Address - Phone:618-993-0307
Practice Address - Fax:618-993-0807
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-092538207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0360925381Medicaid
IL10032027OtherBLUE CROSS BLUE SHIELD
ID0360925381Medicaid
IL214881Medicare Oscar/Certification
IL205790Medicare PIN
ILL98655Medicare PIN