Provider Demographics
NPI:1093910879
Name:MANIKAL, VIVEK M (MD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:M
Last Name:MANIKAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:100 WHETSTONE PL STE 205
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5775
Mailing Address - Country:US
Mailing Address - Phone:904-819-9925
Mailing Address - Fax:904-819-9926
Practice Address - Street 1:1093 A1A BEACH BLVD PMB415
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080
Practice Address - Country:US
Practice Address - Phone:904-819-9925
Practice Address - Fax:904-819-9926
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 0080064207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259185500Medicaid
FL35271OtherBCBS
FLK7712Medicare ID - Type Unspecified
FL35271OtherBCBS