Healthcare Provider Details

I. General information

NPI: 1841752318
Provider Name (Legal Business Name): SUDHIR MANICKAVEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 WILSHIRE BLVD
LOS ANGELES CA
90017-4810
US

IV. Provider business mailing address

18006 BLACK GOLD WAY
BOYDS MD
20841-6000
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-9930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberA194289
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: