Provider Demographics
NPI:1487614723
Name:EUSTACE, MANOHARAN W (MD)
Entity type:Individual
Prefix:
First Name:MANOHARAN
Middle Name:W
Last Name:EUSTACE
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 1:1032 N IRISH RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-2209
Mailing Address - Country:US
Mailing Address - Phone:810-658-2131
Mailing Address - Fax:810-658-3500
Practice Address - Street 1:1032 N IRISH RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-2209
Practice Address - Country:US
Practice Address - Phone:810-658-2131
Practice Address - Fax:810-658-3500
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIME056842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3E22022OtherHEALTH PLUS
MIC3246OtherM CARE
MI110250037OtherBCBS M
MI4203754Medicaid
MI0250037OtherBLUE CARE NETWORK
MI3E22022OtherHEALTH PLUS
MI110250037OtherBCBS M