Healthcare Provider Details

I. General information

NPI: 1841511284
Provider Name (Legal Business Name): MANOJ PRAKASH MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2758 US 1 S
ST AUGUSTINE FL
32086-6343
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 Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MANOJ PRAKASH
Title or Position: OWNER
Credential: MD
Phone: 904-797-2338