Provider Demographics
NPI:1801980594
Name:MANIKTALA, SURJIT S (MD)
Entity type:Individual
Prefix:
First Name:SURJIT
Middle Name:S
Last Name:MANIKTALA
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 1:30 MEADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7122
Mailing Address - Country:US
Mailing Address - Phone:508-584-9520
Mailing Address - Fax:
Practice Address - Street 1:30 MEADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7122
Practice Address - Country:US
Practice Address - Phone:508-584-9520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53518207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA764557OtherTUFTS HEALTH PLAN
MA110057924AMedicaid
MAJ13686OtherBC/BS
MA110211580OtherRAIL ROAD MEDICARE
MA698120OtherHARVARD PILGRIM HEALTH CA
MAJ13686Medicare PIN
MAF54237Medicare UPIN