Provider Demographics
NPI:1912969775
Name:DERASARI, MANJUL DILIPBHAI
Entity Type:Individual
Prefix:
First Name:MANJUL
Middle Name:DILIPBHAI
Last Name:DERASARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:352-567-0188
Mailing Address - Fax:813-355-5084
Practice Address - Street 1:36763 EILAND BLVD STE 201
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542
Practice Address - Country:US
Practice Address - Phone:813-977-6688
Practice Address - Fax:813-355-5060
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0054111174400000X
FLME54111208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064751900Medicaid
FL39715OtherMEDICARE PTAN GROUP
FL11609ROtherMEDICARE PTAN
FL064751900Medicaid