Basic Information
| Provider Information | |||||||||
| NPI: | 1316052673 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA SERNA | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | LOW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 HASKINS RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434021600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193537069 | ||||||||
| FaxNumber: | 4193537076 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 W WOOSTER ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434022644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193521404 | ||||||||
| FaxNumber: | 4193544323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35035987 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0222619 | 05 | OH | MEDICAID |