Provider Demographics
NPI:1689835357
Name:DERASARI, KALYANI MANJUL (MD)
Entity Type:Individual
Prefix:DR
First Name:KALYANI
Middle Name:MANJUL
Last Name:DERASARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KALYANI
Other - Middle Name:MANJUL
Other - Last Name:DERASARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-2812
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:SHS-100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-9951
Practice Address - Country:US
Practice Address - Phone:813-974-2331
Practice Address - Fax:813-974-7181
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52057208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05667OtherBLUE CROSS BLUE SHIELD
FL000199700Medicaid
FL05667OtherBLUE CROSS BLUE SHIELD