Provider Demographics
NPI:1588730675
Name:IDROGO, MANUEL A (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:IDROGO
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 1:580 RICE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-2148
Mailing Address - Country:US
Mailing Address - Phone:651-227-6551
Mailing Address - Fax:651-665-0684
Practice Address - Street 1:580 RICE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2148
Practice Address - Country:US
Practice Address - Phone:651-227-6551
Practice Address - Fax:651-665-0684
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1012167OtherPREFERRED ONE
MN109254OtherUCARE
MN58D76INOtherBCBS
MN01-10998OtherMEDICA
MN225019500Medicaid
MN768169OtherAMERICA'S PPO
MNHP21967OtherHEALTHPARTNERS
IA2516896Medicaid
WI31738900Medicaid
MN225019500Medicaid
MN01-10998OtherMEDICA