Provider Demographics
NPI: | 1932143112 |
---|---|
Name: | VARA, MANJULA (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MANJULA |
Middle Name: | |
Last Name: | VARA |
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: | 380 RAMONA AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | STATEN ISLAND |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10312-2611 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 917-670-4695 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1818 E ELIZABETH AVE |
Practice Address - Street 2: | |
Practice Address - City: | LINDEN |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 07036-1410 |
Practice Address - Country: | US |
Practice Address - Phone: | 908-583-5421 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-16 |
Last Update Date: | 2023-10-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 144214 | 207ZP0101X |
NJ | 25MA0387750 | 207ZP0102X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No | 207ZP0101X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NJ | 0074187 | Medicaid | |
NJ | 0074187 | Medicaid | |
NY | E62512 | Medicare UPIN | |
NY | 66F951 | Medicare UPIN |