Basic Information
| Provider Information | |||||||||
| NPI: | 1912969775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERASARI | ||||||||
| FirstName: | MANJUL | ||||||||
| MiddleName: | DILIPBHAI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525670188 | ||||||||
| FaxNumber: | 8133555084 | ||||||||
| Practice Location | |||||||||
| Address1: | 36763 EILAND BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139776688 | ||||||||
| FaxNumber: | 8133555060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0054111 | FL | N | Other Service Providers | Specialist | 208VP0014X | ME54111 | FL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 064751900 | 05 | FL | MEDICAID | 39715 | 01 | FL | MEDICARE PTAN GROUP | OTHER | 11609R | 01 | FL | MEDICARE PTAN | OTHER |