Provider Demographics
NPI:1013217629
Name:MANHATTAN AVENUE MEDICAL PC
Entity Type:Organization
Organization Name:MANHATTAN AVENUE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AZU
Authorized Official - Middle Name:A
Authorized Official - Last Name:AJUDUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-933-4445
Mailing Address - Street 1:552 EAST 180TH STREET
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-3304
Mailing Address - Country:US
Mailing Address - Phone:718-933-4445
Mailing Address - Fax:718-933-4444
Practice Address - Street 1:552 EAST 180TH STREET
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-3304
Practice Address - Country:US
Practice Address - Phone:718-933-4445
Practice Address - Fax:718-933-4444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty