Healthcare Provider Details

I. General information

NPI: 1932499290
Provider Name (Legal Business Name): GREGORY MANIATIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SEAVIEW AVE STE 200
STATEN ISLAND NY
10305-3400
US

IV. Provider business mailing address

163 DRAKE AVE
STATEN ISLAND NY
10314-3011
US

V. Phone/Fax

Practice location:
  • Phone: 718-663-6400
  • Fax:
Mailing address:
  • Phone: 718-490-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number284475-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: