Provider Demographics
NPI:1972587038
Name:DAW, MANJAREE (MD)
Entity Type:Individual
Prefix:
First Name:MANJAREE
Middle Name:
Last Name:DAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10080 SW INNOVATION WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2127
Mailing Address - Country:US
Mailing Address - Phone:407-580-5052
Mailing Address - Fax:
Practice Address - Street 1:10080 SW INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2127
Practice Address - Country:US
Practice Address - Phone:407-580-5052
Practice Address - Fax:407-580-5052
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME160719207R00000X
CT037747207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001377474Medicaid
CT010037747CT03OtherANTHEM BLUE SHIELD
CT010037747CT03OtherANTHEM BLUE SHIELD
CTH56313Medicare UPIN