Provider Demographics
NPI:1235703141
Name:SRIVILLIBHUTHUR, MANASA (MD)
Entity Type:Individual
Prefix:
First Name:MANASA
Middle Name:
Last Name:SRIVILLIBHUTHUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANASA
Other - Middle Name:
Other - Last Name:SRIVILLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4741
Mailing Address - Fax:401-444-4445
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-4741
Practice Address - Fax:401-444-4445
Is Sole Proprietor?:No
Enumeration Date:2021-05-15
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI05310390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program