Basic Information
| Provider Information | |||||||||
| NPI: | 1871662361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANOHARAN | ||||||||
| FirstName: | PRASAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 REGIMENTAL PL | ||||||||
| Address2: | |||||||||
| City: | NEW WINDSOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125535621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185412168 | ||||||||
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| Practice Location | |||||||||
| Address1: | 70 DUBOIS ST | ||||||||
| Address2: | ST LUKES CORNWALL HOSPITAL | ||||||||
| City: | NEWBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125504851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455614400 | ||||||||
| FaxNumber: | 8457902675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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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 | 207L00000X | 002681-1 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME133099 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 02824679 | 05 | NY | MEDICAID |