Provider Demographics
NPI:1457422982
Name:MANICKAM, NATARAJAN (MD)
Entity Type:Individual
Prefix:
First Name:NATARAJAN
Middle Name:
Last Name:MANICKAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 SMITH CHURCH ROAD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-4914
Mailing Address - Country:US
Mailing Address - Phone:252-537-0134
Mailing Address - Fax:252-537-6515
Practice Address - Street 1:270 SMITH CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4914
Practice Address - Country:US
Practice Address - Phone:252-537-0134
Practice Address - Fax:252-537-6515
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32778207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
110179483OtherRAIL ROAD MEDICARE
18619OtherCAPITOL BC PENN
5843073OtherVIRGINIA MEDICAID
VA028182OtherVABCBS
40991OtherMEDCOST
48 55339OtherUNITED HEALTHCARE
NC53872OtherBCBSNC
20384900OtherDIVISION OF COAL MINERS
NC8953972Medicaid
20384900OtherDIVISION OF COAL MINERS
110179483OtherRAIL ROAD MEDICARE