Provider Demographics
NPI:1972779072
Name:DAVID L MANZO MD PC
Entity type:Organization
Organization Name:DAVID L MANZO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-541-4200
Mailing Address - Street 1:621 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2201
Mailing Address - Country:US
Mailing Address - Phone:248-541-4200
Mailing Address - Fax:248-541-4969
Practice Address - Street 1:621 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2201
Practice Address - Country:US
Practice Address - Phone:248-541-4200
Practice Address - Fax:248-541-4969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4113369OtherAETNA
MI4229975 TYPE 10Medicaid
MI1806373281OtherBLUE CROSS/BLUE SHIELD OF MI
MIF01746Medicare UPIN
MI4113369OtherAETNA