Basic Information
| Provider Information | |||||||||
| NPI: | 1578843496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANTRALA | ||||||||
| FirstName: | PRANITHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1351 ROUTE 55 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAGRANGEVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125405108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454759661 | ||||||||
| FaxNumber: | 8454759938 | ||||||||
| Practice Location | |||||||||
| Address1: | 670 STONELEIGH AVE | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105123997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452795711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2011 | ||||||||
| LastUpdateDate: | 01/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 276789 | NY | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 276789 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03914463 | 05 | NY | MEDICAID |