Provider Demographics
NPI:1790771756
Name:MAHANIAH, KIAME JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:KIAME
Middle Name:JACKSON
Last Name:MAHANIAH
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 1:47 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-7308
Mailing Address - Country:US
Mailing Address - Phone:978-744-8388
Mailing Address - Fax:
Practice Address - Street 1:47 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-7308
Practice Address - Country:US
Practice Address - Phone:978-744-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA36201Medicare ID - Type Unspecified
H11845Medicare UPIN