Provider Demographics
NPI:1790046399
Name:RAYTHATHA, MANISHA SURENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MANISHA
Middle Name:SURENDRA
Last Name:RAYTHATHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 W ROSE GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-2530
Mailing Address - Country:US
Mailing Address - Phone:602-521-6252
Mailing Address - Fax:623-842-5640
Practice Address - Street 1:6424 E BROADWAY RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1750
Practice Address - Country:US
Practice Address - Phone:480-456-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ555062085R0202X
MI20878752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ401584Medicaid