Provider Demographics
NPI:1235703141
Name:SRIVILLIBHUTHUR, MANASA (MD)
Entity type:Individual
Prefix:
First Name:MANASA
Middle Name:
Last Name:SRIVILLIBHUTHUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANASA
Other - Middle Name:
Other - Last Name:SRIVILLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5200 EASTERN AVE RM 260
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2734
Mailing Address - Country:US
Mailing Address - Phone:410-550-5018
Mailing Address - Fax:410-550-2972
Practice Address - Street 1:5200 EASTERN AVE RM 260
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2734
Practice Address - Country:US
Practice Address - Phone:410-550-5018
Practice Address - Fax:410-550-2972
Is Sole Proprietor?:No
Enumeration Date:2021-05-15
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI05310390200000X
MDD0100300208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program