Provider Demographics
NPI:1255434312
Name:SOUS, MANAL ANN (MD)
Entity type:Individual
Prefix:MRS
First Name:MANAL
Middle Name:ANN
Last Name:SOUS
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 1:637 WYCOFF AVE
Mailing Address - Street 2:SECOND FLOOR OFFICE 3
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481
Mailing Address - Country:US
Mailing Address - Phone:201-848-0700
Mailing Address - Fax:201-848-0677
Practice Address - Street 1:637 WYCOFF AVE
Practice Address - Street 2:SECOND FLOOR OFFICE 3
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481
Practice Address - Country:US
Practice Address - Phone:201-848-0700
Practice Address - Fax:201-848-0677
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA665032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8312800Medicaid
NJ022775Medicare ID - Type Unspecified