Provider Demographics
NPI:1104090935
Name:MANNAM, PRASHANTH
Entity type:Individual
Prefix:DR
First Name:PRASHANTH
Middle Name:
Last Name:MANNAM
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:PRASHANTH
Other - Middle Name:
Other - Last Name:MANNAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1170 CASTLE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4810
Mailing Address - Country:US
Mailing Address - Phone:212-600-8540
Mailing Address - Fax:
Practice Address - Street 1:1170 CASTLE HILL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4810
Practice Address - Country:US
Practice Address - Phone:212-600-8540
Practice Address - Fax:719-792-6001
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03231734Medicaid