Basic Information
| Provider Information | |||||||||
| NPI: | 1558625863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANUEL | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | AZANZA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25487 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342772487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412025342 | ||||||||
| FaxNumber: | 8552534836 | ||||||||
| Practice Location | |||||||||
| Address1: | 5831 BEE RIDGE RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342335094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413798481 | ||||||||
| FaxNumber: | 9413793781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2012 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301100603 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60840812 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2015021634 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME146621 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2108219 | 05 | WA | MEDICAID | 1558625863 | 05 | MO | MEDICAID |