Provider Demographics
NPI:1790816510
Name:KURUVILLA, MANJUMMELKUDIYIL P (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJUMMELKUDIYIL
Middle Name:P
Last Name:KURUVILLA
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 1:15 CEDAR RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7936
Mailing Address - Country:US
Mailing Address - Phone:631-968-9102
Mailing Address - Fax:
Practice Address - Street 1:9 4TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7908
Practice Address - Country:US
Practice Address - Phone:631-968-9102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128155-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYK043K961Medicare ID - Type Unspecified
NYB14114Medicare UPIN