Provider Demographics
NPI:1053660258
Name:SHIVPUTRA, MANJULA WARAD (DPM)
Entity type:Individual
Prefix:DR
First Name:MANJULA
Middle Name:WARAD
Last Name:SHIVPUTRA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:MANJULA
Other - Middle Name:VALLABH
Other - Last Name:JANARDHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:17-31 60TH LANE
Mailing Address - Street 2:APT #311
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385
Mailing Address - Country:US
Mailing Address - Phone:347-398-7787
Mailing Address - Fax:
Practice Address - Street 1:17-31 60TH LANE
Practice Address - Street 2:APT #311
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:347-398-7787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYS PERMIT P80993213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery