MEDICARE: MANI JACOB KALLUPURACKAL DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1154171650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANI JACOB KALLUPURACKAL DO

Provider Business Mailing Address
First Line	:	1350 S KINGS DR FL 3
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-2134
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 S KINGS DR FL 3
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-2134
Country	:	US
Telephone Number	:	704-446-1242
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2024
Last Update Date	:	04/24/2026

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