Provider Demographics
NPI:1255790796
Name:MANTHURUTHIL, ERIC (PA-C)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:MANTHURUTHIL
Suffix:
Gender:M
Credentials:PA-C
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 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7208
Mailing Address - Country:US
Mailing Address - Phone:817-707-5636
Mailing Address - Fax:
Practice Address - Street 1:5939 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390
Practice Address - Country:US
Practice Address - Phone:214-645-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-12
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA10504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant