Provider Demographics
NPI:1861586331
Name:MANCE, CORNELIUS JEFFERSON (MD)
Entity type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:JEFFERSON
Last Name:MANCE
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 1:2051 HAMILL RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343
Mailing Address - Country:US
Mailing Address - Phone:423-877-1212
Mailing Address - Fax:423-877-6793
Practice Address - Street 1:2051 HAMILL RD
Practice Address - Street 2:STE 302
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-6614
Practice Address - Country:US
Practice Address - Phone:423-877-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD85542084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3074846OtherBLUECROSS / BLUESHIELD
TN3046304Medicaid
TN3074846OtherBLUECROSS / BLUESHIELD
C36500Medicare UPIN