Provider Demographics
NPI:1326068198
Name:MUTYALA, MANIKYAM (MD)
Entity Type:Individual
Prefix:
First Name:MANIKYAM
Middle Name:
Last Name:MUTYALA
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 1:276 85TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-1205
Mailing Address - Country:US
Mailing Address - Phone:516-358-1674
Mailing Address - Fax:
Practice Address - Street 1:276 85TH AVE
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-1205
Practice Address - Country:US
Practice Address - Phone:516-358-1674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229717-1207P00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02559171Medicaid
NYON9821Medicare ID - Type Unspecified
NY02559171Medicaid