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General NPI Number Information
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NPI Number | 1932319753
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Entity Type | Individual
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Provider Name | GAYATHRI N MANICKAM M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 11/03/2023
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Provider Practice Location Address
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Address Line | 4401 CONNER ST
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City | DETROIT
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State | MI
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Zip | 48215-2201
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Country | US
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Telephone | 313-823-9800
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Fax |
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Provider Business Mailing Address
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Address Line | 2852 BIRCHDALE DR
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City | TROY
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State | MI
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Zip | 48083-6809
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Country | US
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Telephone | 720-771-7792
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301085440
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 4301085440
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License Number State | MI
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