1154353654 NPI number — PREMALATA MANICKAM M.D.

Table of content: PREMALATA MANICKAM M.D. (NPI 1154353654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154353654 NPI number — PREMALATA MANICKAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANICKAM
Provider First Name:
PREMALATA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1154353654
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9985 SIERRA AVE
Provider Second Line Business Mailing Address:
KAISER PERMANENTE ,PEDIATRIC CLINIC MOB 2B
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92335-6720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-427-5993
Provider Business Mailing Address Fax Number:
909-427-4287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9985 SIERRA AVE
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE, MOB 2B
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92335-6720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-427-5993
Provider Business Practice Location Address Fax Number:
909-427-4287
Provider Enumeration Date:
07/07/2006

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: 208000000X , with the licence number:  C52156 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3386785 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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