Provider Demographics
NPI:1215011150
Name:MANICKAVASAGAR, MARIE J (MD)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:J
Last Name:MANICKAVASAGAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIE
Other - Middle Name:J
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:830 SOUTHAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1001
Mailing Address - Country:US
Mailing Address - Phone:757-683-2889
Mailing Address - Fax:757-683-2740
Practice Address - Street 1:830 SOUTHAMPTON AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1001
Practice Address - Country:US
Practice Address - Phone:757-683-2889
Practice Address - Fax:757-683-2740
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101023631207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF84662Medicare UPIN
VA00V453C38Medicare PIN