Provider Demographics
NPI:1376770826
Name:MANUS PRASERTHDAM,M.D.,P.A
Entity Type:Organization
Organization Name:MANUS PRASERTHDAM,M.D.,P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUS
Authorized Official - Middle Name:
Authorized Official - Last Name:PRASERTHDAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-894-1122
Mailing Address - Street 1:1201 5TH AVE N STE 208
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1410
Mailing Address - Country:US
Mailing Address - Phone:727-894-1122
Mailing Address - Fax:727-894-0033
Practice Address - Street 1:1201 5TH AVE N STE 208
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1410
Practice Address - Country:US
Practice Address - Phone:727-894-1122
Practice Address - Fax:727-894-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0666950OtherAETNA
FL62149Medicaid
FL0184828OtherCIGNA
FL212769OtherAMERIGROUP
FL3106012OtherUNITED HEALTHCARE
FLD57315Medicare UPIN