Provider Demographics
NPI:1679560486
Name:MANISCALCO, BENEDICT S (MD)
Entity Type:Individual
Prefix:
First Name:BENEDICT
Middle Name:S
Last Name:MANISCALCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6383
Mailing Address - Country:US
Mailing Address - Phone:813-873-0000
Mailing Address - Fax:813-873-3659
Practice Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD STE 800
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6065
Practice Address - Country:US
Practice Address - Phone:813-873-0000
Practice Address - Fax:813-873-3659
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0014584174400000X
FLME14584207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME14584OtherSTATE LICENSE#
FL060069442OtherRR MEDICARE
FL059148300Medicaid
FL060069442OtherRR MEDICARE
D53794Medicare UPIN