MEDICARE: DR. SUDHIR MANICKAVEL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207YX0901X	Otology & Neurotology Physician	A194289	CA

General Provider Information

NPI Number	:	1841752318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUDHIR MANICKAVEL MD

Provider Business Mailing Address
First Line	:	18006 BLACK GOLD WAY
Second Line	:
City	:	BOYDS
State	:	MD
Zip	:	20841-6000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1245 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4810
Country	:	US
Telephone Number	:	213-483-9930
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2019
Last Update Date	:	06/08/2026

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