Provider Demographics
NPI:1447276852
Name:MANIKAL, MONALI (MD)
Entity type:Individual
Prefix:
First Name:MONALI
Middle Name:
Last Name:MANIKAL
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 1:1093 A1A BEACH BLVD
Mailing Address - Street 2:PMB 415
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6733
Mailing Address - Country:US
Mailing Address - Phone:904-819-9925
Mailing Address - Fax:904-819-9926
Practice Address - Street 1:100 WHETSTONE PL
Practice Address - Street 2:SUITES 205
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5774
Practice Address - Country:US
Practice Address - Phone:904-819-9925
Practice Address - Fax:904-819-9926
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 81118208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259789600Medicaid
FL259789600Medicaid