Provider Demographics
NPI:1922084433
Name:MANIAM, PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASH
Middle Name:
Last Name:MANIAM
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 1:8400 RED BUG LAKE RD STE 1010
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6835
Mailing Address - Country:US
Mailing Address - Phone:407-302-2620
Mailing Address - Fax:
Practice Address - Street 1:410 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 1500B
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6810
Practice Address - Country:US
Practice Address - Phone:803-643-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27620174400000X
FLME134141208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC276203Medicaid
SC276203Medicaid
SC8708Medicare PIN
SCH58026Medicare UPIN