Provider Demographics
NPI:1801321708
Name:MANIVANNAN, SURYA (MD)
Entity type:Individual
Prefix:DR
First Name:SURYA
Middle Name:
Last Name:MANIVANNAN
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 1:102 MASON FARM RD
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599-6134
Mailing Address - Country:US
Mailing Address - Phone:919-966-1459
Mailing Address - Fax:919-843-2356
Practice Address - Street 1:102 MASON FARM RD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-6134
Practice Address - Country:US
Practice Address - Phone:919-966-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC227552390200000X
NC2022-01910207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program