Healthcare Provider Details

I. General information

NPI: 1649408956
Provider Name (Legal Business Name): MANOJ PUTHIYATHU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E RIDGEWOOD AVE
PARAMUS NJ
07652-4142
US

IV. Provider business mailing address

61 LINDEN ST APT C9
HACKENSACK NJ
07601-3534
US

V. Phone/Fax

Practice location:
  • Phone: 201-967-4132
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number25MA09523700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: