Healthcare Provider Details

I. General information

NPI: 1588932966
Provider Name (Legal Business Name): KSHEMAL P MANKODI MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28959 WESLEY CHAPEL BLVD
WESLEY CHAPEL FL
33543-3218
US

IV. Provider business mailing address

28959 WESLEY CHAPEL BLVD
WESLEY CHAPEL FL
33543-3218
US

V. Phone/Fax

Practice location:
  • Phone: 813-994-4749
  • Fax: 813-994-0474
Mailing address:
  • Phone: 813-994-4749
  • Fax: 813-994-0474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME78449
License Number StateFL

VIII. Authorized Official

Name: DR. KSHEMAL MANKODI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 813-994-4749