Provider Demographics
NPI:1841360138
Name:THIMMAIAH, MANAVATTIRA B (MD)
Entity type:Individual
Prefix:
First Name:MANAVATTIRA
Middle Name:B
Last Name:THIMMAIAH
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 1:10 GEOFFREY DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405
Mailing Address - Country:US
Mailing Address - Phone:973-492-0818
Mailing Address - Fax:
Practice Address - Street 1:492 STATE ROUTE 57 W
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882-4338
Practice Address - Country:US
Practice Address - Phone:908-689-1000
Practice Address - Fax:908-689-4529
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA034903002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0789500Medicaid
NJ0789500Medicaid
TH446780Medicare ID - Type Unspecified