Healthcare Provider Details

I. General information

NPI: 1912566787
Provider Name (Legal Business Name): MANISHA MANGLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E ADAMS ST
SYRACUSE NY
13210-1834
US

IV. Provider business mailing address

224 HARRISON ST STE 601
SYRACUSE NY
13202-3186
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-7494
  • Fax: 315-464-5189
Mailing address:
  • Phone: 315-464-5660
  • Fax: 315-464-7695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number334749
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number334749
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: