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General NPI Number Information
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NPI Number | 1053320770
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Entity Type | Individual
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Provider Name | MANNTEJ S SRA M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 07/16/2023
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Provider Practice Location Address
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Address Line | 13943 N 91ST AVE BUILDING A, SUITE 102
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City | PEORIA
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State | AZ
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Zip | 85381-3629
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Country | US
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Telephone | 602-705-1353
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Fax | 623-815-8299
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Provider Business Mailing Address
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Address Line | 13943 N 91ST AVE BUILDING A, SUITE 102
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City | PEORIA
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State | AZ
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Zip | 85381-3629
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Country | US
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Telephone | 602-705-1353
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Fax | 623-815-8299
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 28033
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License Number State | AZ
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