Healthcare Provider Details

I. General information

NPI: 1245396787
Provider Name (Legal Business Name): MANTHODI KULANGARA FAISAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4923 OGLETOWN STANTON RD SUITE 200
NEWARK DE
19713-2081
US

IV. Provider business mailing address

4923 OGLETOWN STANTON RD SUITE 200
NEWARK DE
19713-2081
US

V. Phone/Fax

Practice location:
  • Phone: 302-225-0451
  • Fax: 302-225-0472
Mailing address:
  • Phone: 302-225-0451
  • Fax: 302-225-0472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberD0072245
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberC1-0009736
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: