Provider Demographics
NPI:1407915929
Name:MANJUL DERASARI M.D.,P.A.
Entity Type:Organization
Organization Name:MANJUL DERASARI M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MANJUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:DERASARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-933-5900
Mailing Address - Street 1:1912 E BUSCH BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-8666
Mailing Address - Country:US
Mailing Address - Phone:813-933-5900
Mailing Address - Fax:813-935-9687
Practice Address - Street 1:1912 E BUSCH BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-8666
Practice Address - Country:US
Practice Address - Phone:813-933-5900
Practice Address - Fax:813-935-9687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2720607OtherAETNA
FL11609OtherBC BS
FL064751900Medicaid
FL064751900Medicaid
FL050088184Medicare ID - Type UnspecifiedMEDICARE RAILROAD
FLE68773Medicare UPIN
FL2720607OtherAETNA