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NPI Code Detail

MEDICARE: GAYATHRI N MANICKAM M.D.

MEDICARE: GAYATHRI N MANICKAM M.D.
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
1207Q00000XFamily Medicine Physician4301085440MI
2207QS0010XSports Medicine (Family Medicine) Physician4301085440MI

General Provider Information

NPI Number : 1932319753
Entity Type Code : Individual
Provider Name (Legal Business Name) : GAYATHRI N MANICKAM M.D.
Provider Business Mailing Address
First Line : 2852 BIRCHDALE DR
Second Line :
City : TROY
State : MI
Zip : 48083-6809
Country : US
Telephone Number : 720-771-7792
Fax Number :
Provider Business Practice Location Address
First Line : 4401 CONNER ST
Second Line :
City : DETROIT
State : MI
Zip : 48215-2201
Country : US
Telephone Number : 313-823-9800
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2007
Last Update Date : 11/03/2023

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