Healthcare Provider Details

I. General information

NPI: 1831759596
Provider Name (Legal Business Name): MANTAVYA PUNJ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2019
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 SANDIFUR PKWY
PASCO WA
99301-8028
US

IV. Provider business mailing address

550 GAGE BLVD STE 101
RICHLAND WA
99352-9532
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-3170
  • Fax: 509-543-9795
Mailing address:
  • Phone: 509-946-4611
  • Fax: 509-627-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTRN29309
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License NumberMD61357479
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberME154593
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61357479
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: