Provider Demographics
NPI:1013148576
Name:MANYAM, MALIKA (MD)
Entity Type:Individual
Prefix:DR
First Name:MALIKA
Middle Name:
Last Name:MANYAM
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:PO BOX 2695
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20195-0695
Mailing Address - Country:US
Mailing Address - Phone:703-943-7475
Mailing Address - Fax:
Practice Address - Street 1:1860 TOWN CENTER DR STE 340
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5912
Practice Address - Country:US
Practice Address - Phone:703-943-7475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-01
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN52199208M00000X
VA0101251555208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1013148576Medicaid