Provider Demographics
NPI:1497243703
Name:MANNAN, AYESHA (DO)
Entity Type:Individual
Prefix:
First Name:AYESHA
Middle Name:
Last Name:MANNAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:631-376-3420
Practice Address - Street 1:515 BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5005
Practice Address - Country:US
Practice Address - Phone:631-667-0388
Practice Address - Fax:631-968-7705
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY308856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program