Provider Demographics
NPI:1306877972
Name:PULICOTTIL, MANOJ (MD)
Entity type:Individual
Prefix:
First Name:MANOJ
Middle Name:
Last Name:PULICOTTIL
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 1:4205 BELFORT RD
Mailing Address - Street 2:JOE ADAMS BLDG, SUITE 2005
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5876
Mailing Address - Country:US
Mailing Address - Phone:904-398-5123
Mailing Address - Fax:904-399-1962
Practice Address - Street 1:4205 BELFORT RD
Practice Address - Street 2:JOE ADAMS BLDG, SUITE 2005
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5876
Practice Address - Country:US
Practice Address - Phone:904-398-5123
Practice Address - Fax:904-399-1962
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055273207R00000X
MA234503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2149702Medicaid
GA412705254AMedicaid
GA412705254AMedicaid
MA2149702Medicaid
GAI27648Medicare UPIN