Provider Demographics
NPI:1427664531
Name:MANIMALA, JIBIN
Entity type:Individual
Prefix:
First Name:JIBIN
Middle Name:
Last Name:MANIMALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HILLVIEW PL
Mailing Address - Street 2:
Mailing Address - City:ELMSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:10523-2007
Mailing Address - Country:US
Mailing Address - Phone:914-909-0221
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025339363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant