Basic Information
| Provider Information | |||||||||
| NPI: | 1790046399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAYTHATHA | ||||||||
| FirstName: | MANISHA | ||||||||
| MiddleName: | SURENDRA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2323 W ROSE GARDEN LN | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850272530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025216252 | ||||||||
| FaxNumber: | 6238425640 | ||||||||
| Practice Location | |||||||||
| Address1: | 6424 E BROADWAY RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852061750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804569000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2012 | ||||||||
| LastUpdateDate: | 01/31/2019 | ||||||||
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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 | 2085R0202X | 55506 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 401584 | 05 | AZ | MEDICAID |