Provider Demographics
NPI:1477629400
Name:MANTIA MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:MANTIA MEDICAL ASSOCIATES
Other - Org Name:496 NESCONSET HWY SUITE 200 SMITHTOWN NY 11787
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTUS
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-265-9111
Mailing Address - Street 1:496 NESCONSET HIGHWAY
Mailing Address - Street 2:STE 200
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-265-9111
Mailing Address - Fax:
Practice Address - Street 1:496 NESCONSET HIGHWAY
Practice Address - Street 2:STE 200
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-265-9111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182606207Q00000X
NY094617207R00000X
NY124142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY155862Medicaid
NY2785973Medicaid
NY1577013Medicaid
NY336901Medicare ID - Type Unspecified
NYC08698Medicare UPIN
NY20H921Medicare ID - Type Unspecified
NY1577013Medicaid
NY155862Medicaid
NY2785973Medicaid