Basic Information
| Provider Information | |||||||||
| NPI: | 1629070131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANFREDI | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782889555 | ||||||||
| FaxNumber: | 6782889556 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 DEEP SOUTH FARM RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BLAIRSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305122218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068352235 | ||||||||
| FaxNumber: | 7068351706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 04/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 16101 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000011382K | 05 | GA | MEDICAID | 000011382M | 05 | GA | MEDICAID |