Provider Demographics
NPI:1558775973
Name:MANI VASCULAR SURGERY PLLC
Entity Type:Organization
Organization Name:MANI VASCULAR SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:MANIKYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-313-5639
Mailing Address - Street 1:340 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3031
Mailing Address - Country:US
Mailing Address - Phone:516-513-5639
Mailing Address - Fax:
Practice Address - Street 1:6519 BORDEN AVE
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1630
Practice Address - Country:US
Practice Address - Phone:516-513-5639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2297172086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY229717OtherLICENSE