Basic Information
| Provider Information | |||||||||
| NPI: | 1518304625 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANOCHA | ||||||||
| FirstName: | KEVIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 603949 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282603949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500351 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192319623 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2013 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 58109 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0001X | 2021-01012 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 1518304625 | 05 | NC | MEDICAID |