Provider Demographics
NPI:1285682872
Name:MANISCALCO, JACK EARL (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EARL
Last Name:MANISCALCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2816 W VIRGINIA AVE
Mailing Address - Street 2:NEUROLOGICAL SPECIALTIES NEUROSURGERY PA
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6330
Mailing Address - Country:US
Mailing Address - Phone:813-876-6321
Mailing Address - Fax:813-870-0350
Practice Address - Street 1:2816 W VIRGINIA AVE
Practice Address - Street 2:NEUROLOGICAL SPECIALTIES NEUROSURGERY PA
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6330
Practice Address - Country:US
Practice Address - Phone:813-876-6321
Practice Address - Fax:813-870-0350
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0023743207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
406143136OtherRAILROAD MEDICARE
F70917030OtherCHAMPUS
FLME0023743OtherMEDICAL LICENSE
FL059512800Medicaid
FL71703OtherBCBS
406143136OtherRAILROAD MEDICARE
F70917030OtherCHAMPUS
D58160Medicare UPIN