Provider Demographics
NPI:1871773143
Name:MANNY, THEODORE BERGEN JR (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:BERGEN
Last Name:MANNY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TED
Other - Middle Name:BERGEN
Other - Last Name:MANNY
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:509 N ELAM AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1157
Mailing Address - Country:US
Mailing Address - Phone:336-274-1114
Mailing Address - Fax:336-232-5325
Practice Address - Street 1:509 N ELAM AVE FL 2
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1157
Practice Address - Country:US
Practice Address - Phone:336-274-1114
Practice Address - Fax:336-274-9638
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00902208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5921067Medicaid
NC5921067Medicaid