Healthcare Provider Details

I. General information

NPI: 1629432463
Provider Name (Legal Business Name): MANISH ASHOK SHAHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 11/15/2025
Certification Date: 11/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13330 USF LAUREL DR
TAMPA FL
33612-6601
US

IV. Provider business mailing address

PO BOX 917770
ORLANDO FL
32891-0001
US

V. Phone/Fax

Practice location:
  • Phone: 813-821-8038
  • Fax:
Mailing address:
  • Phone: 813-821-8038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number42658
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberME176105
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: