Provider Demographics
NPI:1154353654
Name:MANICKAM, PREMALATA (MD)
Entity type:Individual
Prefix:
First Name:PREMALATA
Middle Name:
Last Name:MANICKAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9985 SIERRA AVE
Mailing Address - Street 2:KAISER PERMANENTE ,PEDIATRIC CLINIC MOB 2B
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6720
Mailing Address - Country:US
Mailing Address - Phone:909-427-5993
Mailing Address - Fax:909-427-4287
Practice Address - Street 1:9985 SIERRA AVE
Practice Address - Street 2:KAISER PERMANENTE, MOB 2B
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-5993
Practice Address - Fax:909-427-4287
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC52156208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3386785Medicaid
MI3386785Medicaid