Provider Demographics
NPI:1902811656
Name:MANAYAN, CONRAD C (DO)
Entity type:Individual
Prefix:
First Name:CONRAD
Middle Name:C
Last Name:MANAYAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 NORTHDALE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1893
Mailing Address - Country:US
Mailing Address - Phone:800-991-6117
Mailing Address - Fax:
Practice Address - Street 1:3525 GEORGE BUSBEE PKWY NW STE 101
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA98137202K00000X, 208600000X
TN1300208600000X
AL0480208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG33475Medicare UPIN