Provider Demographics
NPI:1619127024
Name:REVANKAR, MANASI (DO)
Entity Type:Individual
Prefix:
First Name:MANASI
Middle Name:
Last Name:REVANKAR
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 1:801 OSTRUM ST
Mailing Address - Street 2:ST. LUKE'S ENROLLMENT CENTER
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015
Mailing Address - Country:US
Mailing Address - Phone:484-526-8046
Mailing Address - Fax:
Practice Address - Street 1:185 ROSEBERRY ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1690
Practice Address - Country:US
Practice Address - Phone:484-526-6643
Practice Address - Fax:484-526-4658
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09074300207Q00000X
NY262304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine