Provider Demographics
NPI:1871949883
Name:MANN, SHIVTAJ (DO)
Entity type:Individual
Prefix:
First Name:SHIVTAJ
Middle Name:
Last Name:MANN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8981 COLONIAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7816
Practice Address - Country:US
Practice Address - Phone:239-938-0800
Practice Address - Fax:239-938-0890
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT016993207R00000X
FLOS18673207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology