Provider Demographics
NPI:1205192739
Name:ANASTASIA PEDIATRICS
Entity Type:Organization
Organization Name:ANASTASIA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MONALI
Authorized Official - Middle Name:
Authorized Official - Last Name:MANIKAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-819-9925
Mailing Address - Street 1:100 WHETSTONE PL
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5774
Mailing Address - Country:US
Mailing Address - Phone:904-819-9925
Mailing Address - Fax:904-819-9926
Practice Address - Street 1:100 WHETSTONE PL
Practice Address - Street 2:SUITE 205
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5774
Practice Address - Country:US
Practice Address - Phone:904-819-9925
Practice Address - Fax:904-819-9926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2013-04-30
Deactivation Date:2012-08-31
Deactivation Code:
Reactivation Date:2013-04-30
Provider Licenses
StateLicense IDTaxonomies
FLME0081118208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003482600Medicaid
FL259789600Medicaid