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General NPI Number Information
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NPI Number | 1093034803
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Entity Type | Individual
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Provider Name | MANOJ MADHU SANGORAM D.O.
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Gender | Male
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Dates
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Enumeration Date | 05/19/2010
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Last Update Date | 05/19/2010
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Provider Practice Location Address
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Address Line | 111 E 210TH ST
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City | BRONX
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State | NY
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Zip | 10467-2401
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Country | US
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Telephone | 847-971-6696
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Fax |
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Provider Business Mailing Address
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Address Line | 3450 WAYNE AVE APT. 20G
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City | BRONX
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State | NY
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Zip | 10467-2510
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Country | US
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Telephone | 847-971-6696
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Fax |
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 20A11181
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License Number State | CA
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