Provider Demographics
NPI:1245212570
Name:MATHUR, MANORAMA (MD)
Entity Type:Individual
Prefix:DR
First Name:MANORAMA
Middle Name:
Last Name:MATHUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-4637
Mailing Address - Country:US
Mailing Address - Phone:781-324-6192
Mailing Address - Fax:781-324-2930
Practice Address - Street 1:1127 SALEM ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-4637
Practice Address - Country:US
Practice Address - Phone:781-324-6192
Practice Address - Fax:781-324-2930
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37384208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM08791BOtherMEDICARE PTAN
MA2021544Medicaid
MAE03277Medicare UPIN