Provider Demographics
NPI:1003808049
Name:MANLOVE, JEFFREY C (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:MANLOVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3711
Mailing Address - Country:US
Mailing Address - Phone:612-871-1144
Mailing Address - Fax:612-871-2012
Practice Address - Street 1:2211 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3711
Practice Address - Country:US
Practice Address - Phone:612-871-1144
Practice Address - Fax:612-871-2012
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27919207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0572003OtherPREFERREDONE
MN31360600OtherMEDICAID - WISCONSIN
MN100654OtherUCARE
MN1014249OtherMEDICA CHOICE
MN20938OtherAMERICA'S PPO
MN060087300Medicaid
MN1000010OtherMEDICA PRIMARY
MN38T54MAOtherBLUE SHIELD
MN100654OtherUCARE
MN1000010OtherMEDICA PRIMARY