Provider Demographics
NPI:1497861843
Name:PERSAUD-MANCUSI, ARETHA NANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:ARETHA
Middle Name:NANDA
Last Name:PERSAUD-MANCUSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BROADHOLLOW RD STE 311
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4901
Mailing Address - Country:US
Mailing Address - Phone:631-470-7915
Mailing Address - Fax:631-470-7922
Practice Address - Street 1:150 BROADHOLLOW RD STE 311
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4901
Practice Address - Country:US
Practice Address - Phone:631-470-7915
Practice Address - Fax:631-470-7922
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
349448POtherHIP
NY1396247OtherAETNA
NYP3715262OtherOXFORD
NY5763A1OtherBLUE CROSS AND BLUE SHIELD
NY116432OtherGHI
NYPA8552OtherATLANTIS HEALTHCARE
NY2387689OtherUNITED HEALTHCARE
NY116432OtherGHI
349448POtherHIP