Provider Demographics
NPI:1891787917
Name:PRASERTHDAM, MANUS (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUS
Middle Name:
Last Name:PRASERTHDAM
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 1:1201 5TH AVE N
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1400
Mailing Address - Country:US
Mailing Address - Phone:727-894-1122
Mailing Address - Fax:727-894-0033
Practice Address - Street 1:1201 5TH AVE N
Practice Address - Street 2:SUITE 208
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1400
Practice Address - Country:US
Practice Address - Phone:727-894-1122
Practice Address - Fax:727-894-0033
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33665174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3106012OtherUNITED HEALTHCARE
FL0184828OtherCIGNA
FL0666950OtherAETNA
FL212769OtherAMERIGROUP
FL3106012OtherUNITED HEALTHCARE
FL212769OtherAMERIGROUP