Basic Information
| Provider Information | |||||||||
| NPI: | 1619922796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANZANARES | ||||||||
| FirstName: | MARIAH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 676065 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752676065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 PRESTON RD | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750935102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4695967561 | ||||||||
| FaxNumber: | 4695967560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2003-0415 | NM | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | A016 | 01 | NM | TRICARE | OTHER | 95954791 | 05 | NM | MEDICAID |