Healthcare Provider Details

I. General information

NPI: 1326068198
Provider Name (Legal Business Name): MANIKYAM MUTYALA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 85TH AVE
FLORAL PARK NY
11001-1205
US

IV. Provider business mailing address

14601 45TH AVE STE 315
FLUSHING NY
11355-2280
US

V. Phone/Fax

Practice location:
  • Phone: 516-358-1674
  • Fax:
Mailing address:
  • Phone: 718-670-5473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number229717-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number229717-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: