1831759596 NPI number — MANTAVYA PUNJ MD

Table of content: MANTAVYA PUNJ MD (NPI 1831759596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831759596 NPI number — MANTAVYA PUNJ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUNJ
Provider First Name:
MANTAVYA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831759596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 GAGE BLVD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99352-9532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-946-4611
Provider Business Mailing Address Fax Number:
509-627-2983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9605 SANDIFUR PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASCO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99301-8028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-942-3170
Provider Business Practice Location Address Fax Number:
509-543-9795
Provider Enumeration Date:
06/15/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  TRN29309 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS1201X , with the licence number: MD61357479 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: ME154593 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD61357479 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114769200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".