Basic Information
| Provider Information | |||||||||
| NPI: | 1407828999 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANCHEZ | ||||||||
| FirstName: | MANUEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1028 COOLIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 072083625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739728417 | ||||||||
| FaxNumber: | 9739727173 | ||||||||
| Practice Location | |||||||||
| Address1: | 183 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739728417 | ||||||||
| FaxNumber: | 9739727173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 12/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MA62336 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7440804 | 05 | NJ | MEDICAID |