Healthcare Provider Details

I. General information

NPI: 1235149329
Provider Name (Legal Business Name): MANOJ PRAKASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2758 US 1 SOUTH
ST AUGUSTINE FL
32086
US

IV. Provider business mailing address

PO BOX 860120
ST AUGUSTINE FL
32086-0120
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-2338
  • Fax:
Mailing address:
  • Phone: 904-797-2338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME41060
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME41060
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberME41060
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: