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NPI Code Detail

MEDICARE: SURENDRANATH MANTENA MD

MEDICARE: SURENDRANATH MANTENA MD
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
1207R00000XInternal Medicine Physician01062267AIN
2207R00000XInternal Medicine Physician79241CT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1629172184
Entity Type Code : Individual
Provider Name (Legal Business Name) : SURENDRANATH MANTENA MD
Provider Business Mailing Address
First Line : 267 GRANT ST
Second Line :
City : BRIDGEPORT
State : CT
Zip : 06610-2870
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 267 GRANT ST
Second Line :
City : BRIDGEPORT
State : CT
Zip : 06610-2870
Country : US
Telephone Number : 203-688-4748
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/12/2006
Last Update Date : 09/04/2024

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