Provider Demographics
NPI:1245396787
Name:FAISAL, MANTHODI KULANGARA (MD)
Entity type:Individual
Prefix:
First Name:MANTHODI
Middle Name:KULANGARA
Last Name:FAISAL
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 1:4923 OGLETOWN STANTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2081
Mailing Address - Country:US
Mailing Address - Phone:302-225-0451
Mailing Address - Fax:302-225-0472
Practice Address - Street 1:4923 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2081
Practice Address - Country:US
Practice Address - Phone:302-225-0451
Practice Address - Fax:302-225-0472
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0072245207RN0300X
DEC1-0009736207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019782510001Medicaid
PA2088888OtherHIGHMARK BLUE SHIELD
PA2859911000OtherBCBS
PA1019782510002Medicaid
DE222265ZBZRMedicare PIN
PA2088888OtherHIGHMARK BLUE SHIELD
PA1019782510001Medicaid