Provider Demographics
NPI:1487900494
Name:MANKO, KAREN ELAINE (OD)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:ELAINE
Last Name:MANKO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 PICKETTS CHARGE
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-1469
Mailing Address - Country:US
Mailing Address - Phone:859-341-2566
Mailing Address - Fax:859-341-2568
Practice Address - Street 1:2174 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-2972
Practice Address - Country:US
Practice Address - Phone:859-341-2566
Practice Address - Fax:859-341-2568
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1904DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1904DTOtherSTATE LICENSE
KY7100217150Medicaid
KYK051331Medicare PIN
KYK051330Medicare PIN
KY7100217150Medicaid
KY3344 GROUP NUMBERMedicare PIN