Healthcare Provider Details

I. General information

NPI: 1184865701
Provider Name (Legal Business Name): MANHATTAN WELLNESS MEDICAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 W 44TH ST 10TH FLOOR
NEW YORK NY
10036-6611
US

IV. Provider business mailing address

15 W 44TH ST 10TH FLOOR
NEW YORK NY
10036-6611
US

V. Phone/Fax

Practice location:
  • Phone: 212-575-8910
  • Fax: 212-575-1830
Mailing address:
  • Phone: 212-575-8910
  • Fax: 212-575-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number239417
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number277398
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number256052
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number256704
License Number StateNY

VIII. Authorized Official

Name: TOMONORI NAKAGAMA
Title or Position: MEMBER
Credential: M.D.
Phone: 212-575-8910