Provider Demographics
NPI:1093564874
Name:PUSTAKE, MANAS VAIBHAV (MD)
Entity type:Individual
Prefix:
First Name:MANAS
Middle Name:VAIBHAV
Last Name:PUSTAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 W CASTELLANO DR
Mailing Address - Street 2:APT 3307
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912
Mailing Address - Country:US
Mailing Address - Phone:915-299-9401
Mailing Address - Fax:
Practice Address - Street 1:4800 ALBERTA AVENUE MSC 51009
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905
Practice Address - Country:US
Practice Address - Phone:915-215-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10090533390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program