Provider Demographics
NPI:1013171412
Name:MANICKAVASAGAM, EZHILARASI (MD)
Entity Type:Individual
Prefix:DR
First Name:EZHILARASI
Middle Name:
Last Name:MANICKAVASAGAM
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 1:205 E UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6821
Mailing Address - Country:US
Mailing Address - Phone:512-686-0207
Mailing Address - Fax:
Practice Address - Street 1:2112 SW H K DODGEN LOOP STE 110
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7011
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS2837208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics