Provider Demographics
NPI:1205191699
Name:MANOUSHAGIAN, SHANT JOHN (MD)
Entity type:Individual
Prefix:
First Name:SHANT
Middle Name:JOHN
Last Name:MANOUSHAGIAN
Suffix:
Gender:M
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6860
Mailing Address - Fax:239-343-6162
Practice Address - Street 1:9981 S HEALTHPARK DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3618
Practice Address - Country:US
Practice Address - Phone:239-343-6860
Practice Address - Fax:239-343-6162
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD457729207RC0000X
NY292937207RC0000X
FLME167029207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121555500Medicaid