Provider Demographics
NPI:1609261395
Name:MANICKAM, PERIAKARUPPAN VAIRAVAN (MD)
Entity type:Individual
Prefix:
First Name:PERIAKARUPPAN
Middle Name:VAIRAVAN
Last Name:MANICKAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VAIRAVAN
Other - Middle Name:
Other - Last Name:MANICKAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:300 PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-723-4000
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X207Y00000X
CAA1887922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology