MEDICARE: MANJU KANIKUNNEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	68321	WI
2	207Q00000X	Family Medicine Physician	ME160271	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942615851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANJU KANIKUNNEL

Provider Business Mailing Address
First Line	:	2414 KOHLER MEMORIAL DR
Second Line	:
City	:	SHEBOYGAN
State	:	WI
Zip	:	53081-3129
Country	:	US
Telephone Number	:	920-457-4461
Fax Number	:

Provider Business Practice Location Address
First Line	:	9975 TAVISTOCK LAKES BLVD STE 220
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32827-7665
Country	:	US
Telephone Number	:	407-930-7801
Fax Number	:	407-930-7806

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2014
Last Update Date	:	06/19/2023

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Directions to “ MANJU KANIKUNNEL ” Practice Location

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