Healthcare Provider Details

I. General information

NPI: 1689835357
Provider Name (Legal Business Name): KALYANI MANJUL DERASARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KALYANI MANJUL DERASARI M.D.

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4202 E FOWLER AVE SHS-100
TAMPA FL
33620-9951
US

IV. Provider business mailing address

PO BOX 917770
ORLANDO FL
32891-0001
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-2331
  • Fax: 813-974-7181
Mailing address:
  • Phone: 813-974-2201
  • Fax: 813-974-2812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME52057
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: