Healthcare Provider Details

I. General information

NPI: 1649200965
Provider Name (Legal Business Name): RAJ MANICKAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 SWEET PEA PATH
CROWNSVILLE MD
21032-2020
US

IV. Provider business mailing address

1350 SWEET PEA PATH
CROWNSVILLE MD
21032-2020
US

V. Phone/Fax

Practice location:
  • Phone: 410-987-7375
  • Fax:
Mailing address:
  • Phone: 410-987-7375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0018398
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: