Provider Demographics
NPI:1407352305
Name:JAGALUR MANJUNATHA, NIVEDITHA
Entity Type:Individual
Prefix:
First Name:NIVEDITHA
Middle Name:
Last Name:JAGALUR MANJUNATHA
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 1:4914 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1815
Mailing Address - Country:US
Mailing Address - Phone:240-907-8898
Mailing Address - Fax:
Practice Address - Street 1:9470 ANNAPOLIS RD STE 416
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3000
Practice Address - Country:US
Practice Address - Phone:240-770-3505
Practice Address - Fax:240-770-4303
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-01
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist