Provider Demographics
NPI:1639171606
Name:NALLASIVAN, MANI (MD)
Entity Type:Individual
Prefix:
First Name:MANI
Middle Name:
Last Name:NALLASIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 E YOSEMITE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-8499
Mailing Address - Country:US
Mailing Address - Phone:209-723-6882
Mailing Address - Fax:209-723-6884
Practice Address - Street 1:424 E YOSEMITE AVE STE A
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-8499
Practice Address - Country:US
Practice Address - Phone:209-723-6882
Practice Address - Fax:209-723-6884
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44096207RC0001X, 207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44096OtherLICENSE
CA1982977054Medicaid
CAGR0043810Medicaid
CAGR0043810Medicaid