Basic Information
| Provider Information | |||||||||
| NPI: | 1295177160 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOTHALA | ||||||||
| FirstName: | MANJU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1530 N 7TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478071061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387631 | ||||||||
| FaxNumber: | 8122387003 | ||||||||
| Practice Location | |||||||||
| Address1: | 1530 N 7TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478071061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387631 | ||||||||
| FaxNumber: | 8122387003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2013 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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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 | 11017466A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.