Provider Demographics
NPI:1730178799
Name:MANCHIKANTI, LAXMAIAH (MD)
Entity type:Individual
Prefix:
First Name:LAXMAIAH
Middle Name:
Last Name:MANCHIKANTI
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 1:2831 LONE OAK RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8041
Mailing Address - Country:US
Mailing Address - Phone:270-554-8373
Mailing Address - Fax:270-554-8987
Practice Address - Street 1:2831 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-8041
Practice Address - Country:US
Practice Address - Phone:270-554-8373
Practice Address - Fax:270-554-8987
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20670208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64206709Medicaid
KY000000067584OtherBCBS
ILK07673Medicare ID - Type UnspecifiedMEDICARE
KY050074467Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KY0404402Medicare ID - Type UnspecifiedMEDICARE
KY64206709Medicaid