Provider Demographics
NPI:1780756049
Name:PANAH, MANIZHEH G (MD)
Entity type:Individual
Prefix:DR
First Name:MANIZHEH
Middle Name:G
Last Name:PANAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MANIZHEH
Other - Middle Name:G
Other - Last Name:PANAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:516 HAMBURG TPKE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2062
Mailing Address - Country:US
Mailing Address - Phone:973-790-0006
Mailing Address - Fax:
Practice Address - Street 1:516 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2062
Practice Address - Country:US
Practice Address - Phone:973-790-0006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA35836174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2059100Medicaid
NJ456095Medicare ID - Type UnspecifiedMEDICARE
NJ2059100Medicaid