Provider Demographics
NPI:1316262637
Name:MANAVALAN, PREETI (MD)
Entity type:Individual
Prefix:
First Name:PREETI
Middle Name:
Last Name:MANAVALAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3003
Mailing Address - Country:US
Mailing Address - Phone:352-265-0301
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0001
Practice Address - Country:US
Practice Address - Phone:352-265-0301
Practice Address - Fax:919-681-6448
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT051749207R00000X
NC219164207R00000X
390200000X
FLME146583207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107415000Medicaid