Provider Demographics
NPI:1710091830
Name:GHOSH, MANAS K (MD)
Entity Type:Individual
Prefix:
First Name:MANAS
Middle Name:K
Last Name:GHOSH
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 1:32 ULULANI ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2933
Mailing Address - Country:US
Mailing Address - Phone:808-961-5569
Mailing Address - Fax:808-933-1741
Practice Address - Street 1:32 ULULANI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2933
Practice Address - Country:US
Practice Address - Phone:808-961-5569
Practice Address - Fax:808-933-1741
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
HIMD-2337174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI03268001Medicaid
HI0000036145OtherHMSA
HIC98770Medicare UPIN
HI03268001Medicaid