Provider Demographics
NPI:1083805469
Name:HARIDAS, MANJU SHIVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJU
Middle Name:SHIVAN
Last Name:HARIDAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANJU
Other - Middle Name:SHIVAN
Other - Last Name:THABOLINGAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4729 N HABANA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7113
Mailing Address - Country:US
Mailing Address - Phone:813-251-8444
Mailing Address - Fax:813-254-6414
Practice Address - Street 1:4729 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7113
Practice Address - Country:US
Practice Address - Phone:813-251-8444
Practice Address - Fax:813-254-6414
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301104040207RI0200X
FLME134313207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F39573OtherBLUE CROSS
IL208106010Medicare PIN
MIMI4570Medicare PIN