Basic Information
Provider Information
NPI: 1003804170
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RAWAL
FirstName: MANOJ
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 13460 N 94TH DR STE J1
Address2:  
City: PEORIA
State: AZ
PostalCode: 853814246
CountryCode: US
TelephoneNumber: 6238768816
FaxNumber: 6232980168
Practice Location
Address1: 13460 N 94TH DRIVE
Address2: STE J-1
City: PEORIA
State: AZ
PostalCode: 853814246
CountryCode: US
TelephoneNumber: 6238768816
FaxNumber: 6232980168
Other Information
ProviderEnumerationDate: 10/12/2005
LastUpdateDate: 08/18/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 08/18/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0000X34083AZN Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
207RI0011X34083AZY Allopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology

ID Information
IDTypeStateIssuerDescription
94401805AZ MEDICAID
WCFKQ01AZSUN HEALTH PHYSICIANSOTHER
P0026396701AZMEDICARE RAIL ROADOTHER


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