Healthcare Provider Details

I. General information

NPI: 1003476250
Provider Name (Legal Business Name): MEENAKUMARI MANOHARAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 SAINT SEBASTIAN WAY
AUGUSTA GA
30912-2613
US

IV. Provider business mailing address

997 SAINT SEBASTIAN WAY
AUGUSTA GA
30912-2613
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6597
  • Fax:
Mailing address:
  • Phone: 706-721-6597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number87682
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMT219074
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number87682
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: