Basic Information
| Provider Information | |||||||||
| NPI: | 1174584908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANI | ||||||||
| FirstName: | OBLI | ||||||||
| MiddleName: | CHETTY MARAGATHA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 HANCOCK ST | ||||||||
| Address2: | INTERNAL MEDICINE | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021694339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177740840 | ||||||||
| FaxNumber: | 6177740882 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 HANCOCK ST | ||||||||
| Address2: | INTERNAL MEDICINE | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021694339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177740840 | ||||||||
| FaxNumber: | 6177740882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A89147 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 234649 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A891470 | 05 | CA | MEDICAID | 2161117 | 05 | MA | MEDICAID |