Provider Demographics
NPI:1306803010
Name:MANKOFF, DANIEL MARK (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
Last Name:MANKOFF
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 1:61 COMMERCE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4124
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:SUITE 305
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1006
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044741208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4592429-10Medicaid
MI550410219OtherBCBSM
MI5205950-10Medicaid
MI4532260-10Medicaid
MI4552942-10Medicaid
MI4592429-10Medicaid
A77935Medicare UPIN