Provider Demographics
NPI:1215070396
Name:MANUEL, MERVIN PUNZALAN (MD)
Entity type:Individual
Prefix:DR
First Name:MERVIN
Middle Name:PUNZALAN
Last Name:MANUEL
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 1:116 ARROWHEAD WAY
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1065
Mailing Address - Country:US
Mailing Address - Phone:304-534-0636
Mailing Address - Fax:
Practice Address - Street 1:410 N MAIN ST STE 1-2
Practice Address - Street 2:
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-0866
Practice Address - Country:US
Practice Address - Phone:352-493-7274
Practice Address - Fax:352-493-9290
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123580208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102682978Medicaid