Provider Demographics
NPI:1881871614
Name:GOSHTASBI, MANA (MD)
Entity type:Individual
Prefix:
First Name:MANA
Middle Name:
Last Name:GOSHTASBI
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 1:5410 MARYLAND WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5339
Mailing Address - Country:US
Mailing Address - Phone:615-377-5658
Mailing Address - Fax:888-241-1404
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-870-4933
Practice Address - Fax:813-870-4887
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105162207R00000X
WI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL146N1OtherBCBS
FL001465600Medicaid
FL001465600Medicaid