Healthcare Provider Details

I. General information

NPI: 1184427601
Provider Name (Legal Business Name): MEENAKKSHY MANOHARAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

5830 SW 104TH ST
PINECREST FL
33156-4129
US

V. Phone/Fax

Practice location:
  • Phone: 305-355-1122
  • Fax:
Mailing address:
  • Phone: 954-243-1889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTRN42004
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: