Provider Demographics
NPI:1215554035
Name:THOMAS, MANJU KOYAKKATTU
Entity Type:Individual
Prefix:
First Name:MANJU
Middle Name:KOYAKKATTU
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SADDLE LN
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-6013
Mailing Address - Country:US
Mailing Address - Phone:845-653-6533
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345568-01207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine