Provider Demographics
NPI:1982977054
Name:MANI NALLASIVAN M D INC A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MANI NALLASIVAN M D INC A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANI
Authorized Official - Middle Name:
Authorized Official - Last Name:NALLASIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-723-6882
Mailing Address - Street 1:424 E YOSEMITE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-8499
Mailing Address - Country:US
Mailing Address - Phone:209-723-6882
Mailing Address - Fax:209-723-6884
Practice Address - Street 1:424 E YOSEMITE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-8499
Practice Address - Country:US
Practice Address - Phone:209-383-3456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44096207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty