Healthcare Provider Details

I. General information

NPI: 1639171606
Provider Name (Legal Business Name): MANI NALLASIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 E YOSEMITE AVE STE A
MERCED CA
95340-8499
US

IV. Provider business mailing address

424 E YOSEMITE AVE STE A
MERCED CA
95340-8499
US

V. Phone/Fax

Practice location:
  • Phone: 209-723-6882
  • Fax: 209-723-6884
Mailing address:
  • Phone: 209-723-6882
  • Fax: 209-723-6884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA44096
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberA44096
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberA44096
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: