Provider Demographics
NPI:1215938857
Name:MANNO, DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:MANNO
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 1:1100 LAKE ST STE 125B
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1015
Mailing Address - Country:US
Mailing Address - Phone:708-334-8075
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE ST STE 125B
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1015
Practice Address - Country:US
Practice Address - Phone:708-334-8075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093261207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093261Medicaid
IL036093261Medicaid
L71739Medicare PIN
IL762690Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
930077374Medicare PIN