Basic Information
| Provider Information | |||||||||
| NPI: | 1124077615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANIATIS | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 SEAVIEW AVENUE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189805700 | ||||||||
| FaxNumber: | 7189805499 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SEAVIEW AVENUE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189805700 | ||||||||
| FaxNumber: | 7189805499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 02/28/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 144031 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 0254716002 | 01 | CIGNA | OTHER | 144031 | 01 | HIP | OTHER | 45A661 | 01 | BLUE CROSS | OTHER | 00588472 | 05 | NY | MEDICAID | 165304 | 01 | ELDERPLAN | OTHER | 4C4190 | 01 | TOUCHSTONE | OTHER | 90255 | 01 | AETNA | OTHER | OS117 | 01 | OXFORD | OTHER | 144031C11 | 01 | HEALTHFIRST | OTHER | 4100063 | 01 | GHI | OTHER |