Healthcare Provider Details

I. General information

NPI: 1053408492
Provider Name (Legal Business Name): MANJULA S MANGIPUDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 DR MARTIN LUTHER KING JR ST N SUITE 419
ST PETERSBURG FL
33701-3109
US

IV. Provider business mailing address

700 S HARBOUR ISLAND BLVD UNIT 819
TAMPA FL
33602-5712
US

V. Phone/Fax

Practice location:
  • Phone: 727-820-4231
  • Fax: 727-820-4231
Mailing address:
  • Phone: 813-472-9505
  • Fax: 813-472-9505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberME038891
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: