Provider Demographics
NPI:1427033406
Name:MANI, SHITAL V
Entity Type:Individual
Prefix:DR
First Name:SHITAL
Middle Name:V
Last Name:MANI
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SHITAL
Other - Middle Name:V
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1200 W GODFREY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3323
Mailing Address - Country:US
Mailing Address - Phone:215-276-6000
Mailing Address - Fax:215-276-1329
Practice Address - Street 1:1200 W GODFREY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3323
Practice Address - Country:US
Practice Address - Phone:215-276-6000
Practice Address - Fax:215-276-1329
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002038152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0700258Medicaid
MAW16395OtherBCBS
MA469930OtherTUFTS
MAAA15576OtherHARVARD PILGRIM HEALTH CA
MAU98337Medicare UPIN
MA0700258Medicaid