Provider Demographics
NPI:1487654554
Name:MAMANA, JOHN P (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:MAMANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:PHILIP
Other - Last Name:MAMANA
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:12040 S LAKES DR
Mailing Address - Street 2:SUITE205
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1246
Mailing Address - Country:US
Mailing Address - Phone:703-230-6990
Mailing Address - Fax:703-230-0350
Practice Address - Street 1:12040 S LAKES DR
Practice Address - Street 2:SUITE 205
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1246
Practice Address - Country:US
Practice Address - Phone:703-230-6990
Practice Address - Fax:703-230-6990
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101021602207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA224013OtherTRIGON KEYAD
VA257642OtherMDIPA/OPTIMUM CHOICE/MAMS
VA5820308Medicaid
VA461832OtherAETNA/US HEALTHCARE
VA505114OtherNCPPO
VA45560004OtherBCBS DC CAPCARE
VA5325453-022OtherCIGNA HMO
VA0400438OtherUNITED HEALTH VIRGINIA
VA4092013OtherAHP MGD CHOICE
VA541908735OtherPREFERRED PLAN
VA224013OtherANTHEM HEALTHKEEPERS
VA110184237OtherRAILROAD MEDICARE
VA723576OtherAFFORDABLE FIRST HEALTH
VA0403501OtherUNITED HEALTH MID-ATLANTI
VA541908735OtherCCN
VA541908735OtherPHCS
VA360386OtherONE HEALTH GREATWEST
VA541908735OtherCHAMPUS/TRICARE/STANDARD
VA505114OtherNCPPO
VA5325453-022OtherCIGNA HMO