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General NPI Number Information
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NPI Number | 1790816510
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Entity Type | Individual
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Provider Name | MANJUMMELKUDIYIL P KURUVILLA MD
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Gender | Male
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 10/05/2012
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Provider Practice Location Address
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Address Line | 9 4TH AVE
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City | BAY SHORE
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State | NY
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Zip | 11706-7908
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Country | US
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Telephone | 631-968-9102
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Fax |
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Provider Business Mailing Address
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Address Line | 15 CEDAR RIDGE LN
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City | DIX HILLS
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State | NY
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Zip | 11746-7936
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Country | US
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Telephone | 631-968-9102
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 128155-1
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License Number State | NY
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