Healthcare Provider Details

I. General information

NPI: 1568415859
Provider Name (Legal Business Name): VANI MANYAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 N 6TH 1/2 ST
TERRE HAUTE IN
47804-2700
US

IV. Provider business mailing address

221 S 6TH ST
TERRE HAUTE IN
47807-4214
US

V. Phone/Fax

Practice location:
  • Phone: 812-242-3610
  • Fax: 812-242-3630
Mailing address:
  • Phone: 812-242-3610
  • Fax: 812-242-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number01044408A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number35-07-1650M
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: