Provider Demographics
NPI:1316052673
Name:DE LA SERNA, MANUEL LOW (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:LOW
Last Name:DE LA SERNA
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 1:745 HASKINS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1600
Mailing Address - Country:US
Mailing Address - Phone:419-353-7069
Mailing Address - Fax:419-353-7076
Practice Address - Street 1:960 W WOOSTER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2644
Practice Address - Country:US
Practice Address - Phone:419-352-1404
Practice Address - Fax:419-354-4323
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35035987208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0222619Medicaid
4262311Medicare PIN
OH0222619Medicaid
OH0222619Medicaid