Basic Information
| Provider Information | |||||||||
| NPI: | 1023084571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANTER | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MADISON AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100101600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125452400 | ||||||||
| FaxNumber: | 2124638411 | ||||||||
| Practice Location | |||||||||
| Address1: | 9704 SUTPHIN BLVD | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114354721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186577088 | ||||||||
| FaxNumber: | 7186577092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 07/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 228042 1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00357451 | 05 | NY | MEDICAID | PPO5996243 | 01 | GHI | OTHER | 204590101 | 01 | HEALTHPLUS | OTHER | 40426028484 | 01 | FIDELIS | OTHER | 112467268MA01 | 01 | CAREPLUS | OTHER | PC4845 | 01 | CENTERCARE CHP | OTHER | P3614958 | 01 | OXFORD | OTHER |