Provider Demographics
NPI:1962415604
Name:MANZO, ANDREW ALBERT (DPM)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:ALBERT
Last Name:MANZO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4130
Mailing Address - Country:US
Mailing Address - Phone:516-249-3098
Mailing Address - Fax:
Practice Address - Street 1:665 MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-4130
Practice Address - Country:US
Practice Address - Phone:516-249-3098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0018621213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00414668Medicaid
P10741Medicare ID - Type Unspecified
T50604Medicare UPIN