Provider Demographics
NPI:1053408492
Name:MANGIPUDY, MANJULA S (MD)
Entity type:Individual
Prefix:
First Name:MANJULA
Middle Name:S
Last Name:MANGIPUDY
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 1:700 S HARBOUR ISLAND BLVD
Mailing Address - Street 2:UNIT 819
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5712
Mailing Address - Country:US
Mailing Address - Phone:813-472-9505
Mailing Address - Fax:813-472-9505
Practice Address - Street 1:205 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:SUITE 419
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3109
Practice Address - Country:US
Practice Address - Phone:727-820-4231
Practice Address - Fax:727-820-4231
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME038891207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058380400Medicaid
FL058380400Medicaid
FL30756Medicare ID - Type Unspecified