Provider Demographics
NPI:1588932966
Name:KSHEMAL P MANKODI MD PA
Entity type:Organization
Organization Name:KSHEMAL P MANKODI MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KSHEMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANKODI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-994-4749
Mailing Address - Street 1:28959 WESLEY CHAPEL BLVD
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-3218
Mailing Address - Country:US
Mailing Address - Phone:813-994-4749
Mailing Address - Fax:813-994-0474
Practice Address - Street 1:28959 WESLEY CHAPEL BLVD
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-3218
Practice Address - Country:US
Practice Address - Phone:813-994-4749
Practice Address - Fax:813-994-0474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257244300Medicaid
FLH05837Medicare UPIN