Provider Demographics
NPI:1871079640
Name:MANIGHALAM, MATTHEW SHAHRAM (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SHAHRAM
Last Name:MANIGHALAM
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 1:10050 N WOLFE RD
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-2519
Mailing Address - Country:US
Mailing Address - Phone:714-726-6266
Mailing Address - Fax:
Practice Address - Street 1:10050 N WOLFE RD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2519
Practice Address - Country:US
Practice Address - Phone:408-236-6160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018011141207Q00000X
TX2018011141390200000X
CAA192257261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty