Healthcare Provider Details

I. General information

NPI: 1093910879
Provider Name (Legal Business Name): VIVEK M MANIKAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1093 A1A BEACH BLVD PMB415
ST AUGUSTINE FL
32080
US

IV. Provider business mailing address

100 WHETSTONE PL STE 205
ST AUGUSTINE FL
32086-5775
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-9925
  • Fax: 904-819-9926
Mailing address:
  • Phone: 904-819-9925
  • Fax: 904-819-9926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME 0080064
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: