Basic Information
Provider Information | |||||||||
NPI: | 1700849072 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANNINO | ||||||||
FirstName: | ANTHONY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3630 | ||||||||
Address2: |   | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860033630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9285229879 | ||||||||
FaxNumber: | 9285229880 | ||||||||
Practice Location | |||||||||
Address1: | 126 E MAIN ST | ||||||||
Address2: | STE B | ||||||||
City: | PAYSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9284688610 | ||||||||
FaxNumber: | 9284688605 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2006 | ||||||||
LastUpdateDate: | 06/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO02797 | AZ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 133760 | 05 | AZ |   | MEDICAID | AZ0856210 | 01 |   | BLUE CROSS BLUE SHIELD | OTHER |