Provider Demographics
NPI:1699079434
Name:KEIHANIAN, MANA (MD)
Entity type:Individual
Prefix:
First Name:MANA
Middle Name:
Last Name:KEIHANIAN
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:PO BOX 741729
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 E KIMBALLS LN STE 330
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5006
Practice Address - Country:US
Practice Address - Phone:801-266-3418
Practice Address - Fax:801-266-4174
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11488535-1205207RC0000X
KY44433207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100310290Medicaid
OH0108652Medicaid
KYP01386215OtherRR MEDICARE
KYK155790Medicare PIN