Provider Demographics
NPI:1700961422
Name:MANISCALCO, JENNIFER LEAH (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEAH
Last Name:MANISCALCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEAH
Other - Last Name:DHANIREDDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:501 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4634
Mailing Address - Country:US
Mailing Address - Phone:727-767-4288
Mailing Address - Fax:727-767-8804
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-767-4288
Practice Address - Fax:728-767-8804
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD32477208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403025700Medicaid
VA010022509Medicaid
DC035153400Medicaid
DC035153400Medicaid
H95596Medicare UPIN