Provider Demographics
NPI:1700029741
Name:MANALOOR, NIMMI VARGHESE (MBBS)
Entity Type:Individual
Prefix:
First Name:NIMMI
Middle Name:VARGHESE
Last Name:MANALOOR
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19238 STONEHUE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3447
Practice Address - Country:US
Practice Address - Phone:210-494-2223
Practice Address - Fax:210-941-0142
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014722A208000000X
TXU0157208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201186330Medicaid
INP01512424OtherRR MEDICARE
INP01512424OtherRR MEDICARE