=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841499639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANEKAR MEDICAL CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2007
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1430 FIVE FORKS TRICKUM RD SUITE 220
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-8182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-351-0698
-----------------------------------------------------
Fax | 309-422-8868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1430 FIVE FORKS TRICKUM RD SUITE 220
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-8182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-351-0698
-----------------------------------------------------
Fax | 309-422-8868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JYOTI N MANEKAR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-351-0698
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 057099
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------