Healthcare Provider Details

I. General information

NPI: 1063074086
Provider Name (Legal Business Name): MANOJ B CHAKIATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2019
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26901 76TH AVE
NEW HYDE PARK NY
11040-1433
US

IV. Provider business mailing address

26901 76TH AVE
NEW HYDE PARK NY
11040-1433
US

V. Phone/Fax

Practice location:
  • Phone: 833-462-6436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number345756
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number345756
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: