Healthcare Provider Details

I. General information

NPI: 1205192739
Provider Name (Legal Business Name): ANASTASIA PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date: 08/31/2012
Reactivation Date: 04/30/2013

III. Provider practice location address

100 WHETSTONE PL SUITE 205
ST AUGUSTINE FL
32086-5774
US

IV. Provider business mailing address

100 WHETSTONE PL SUITE 205
ST AUGUSTINE FL
32086-5774
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 Code208000000X
TaxonomyPediatrics Physician
License NumberME0081118
License Number StateFL

VIII. Authorized Official

Name: MONALI MANIKAL
Title or Position: DOCTOR
Credential: MD
Phone: 904-819-9925