Provider Demographics
NPI:1689250078
Name:MANTAS, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MANTAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 MADISON ST APT 502
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3469
Mailing Address - Country:US
Mailing Address - Phone:518-376-0668
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS ROAD
Practice Address - Street 2:HSC LEVEL 4, 050
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:631-444-3880
Practice Address - Fax:631-444-3919
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program