Provider Demographics
NPI:1023342938
Name:MANICKAM, NISHA THANNIKKARY (DO)
Entity type:Individual
Prefix:DR
First Name:NISHA
Middle Name:THANNIKKARY
Last Name:MANICKAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-8000
Mailing Address - Fax:
Practice Address - Street 1:2304 WESVILL CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-0058
Practice Address - Country:US
Practice Address - Phone:919-235-1802
Practice Address - Fax:919-235-1354
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00503207RI0200X
CTUNDER YNHH207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5921923Medicaid