1407882384 NPI number — DAVID W. MANSKY D.P.M.

Table of content: DAVID W. MANSKY D.P.M. (NPI 1407882384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407882384 NPI number — DAVID W. MANSKY D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANSKY
Provider First Name:
DAVID
Provider Middle Name:
W.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407882384
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4310 LEONARD ST NW
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
WALKER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49534-8447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-453-6329
Provider Business Mailing Address Fax Number:
616-453-1725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1127 W STATE ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49058-7754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-945-2222
Provider Business Practice Location Address Fax Number:
269-948-2223
Provider Enumeration Date:
06/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  5901001735 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3108483 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4856351410 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3108483 . This is a "MOLINA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".