Provider Demographics
NPI:1275734717
Name:MANU, DEVARAJAN JYOTHISH (MD)
Entity Type:Individual
Prefix:DR
First Name:DEVARAJAN
Middle Name:JYOTHISH
Last Name:MANU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ATWELL RD
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-1301
Mailing Address - Country:US
Mailing Address - Phone:607-547-6543
Mailing Address - Fax:607-547-3259
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-547-6543
Practice Address - Fax:607-547-3259
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME018645207R00000X
MI4301104920207R00000X
NY282099207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY282099OtherNEW YORK STATE LICENSE
MI4301104920OtherLICENSE