Provider Demographics
NPI:1194987313
Name:JOHN, MANJU MARY
Entity type:Individual
Prefix:
First Name:MANJU
Middle Name:MARY
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 SAYBROOK RD
Mailing Address - Street 2:STE A
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4747
Mailing Address - Country:US
Mailing Address - Phone:860-636-2010
Mailing Address - Fax:860-636-2045
Practice Address - Street 1:420 SAYBROOK RD
Practice Address - Street 2:SUITE A
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4747
Practice Address - Country:US
Practice Address - Phone:860-347-4258
Practice Address - Fax:860-704-5924
Is Sole Proprietor?:No
Enumeration Date:2008-06-29
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT052856207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD40015664Medicare UPIN