=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114000320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANJU LIKKI M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 04/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4337 UNION RD
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45005-5211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-268-6511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6253 ALLISON CT
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45040-5675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-430-2236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35088533
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------