Provider Demographics
NPI:1033129424
Name:MANLY, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:MANLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8010 FROST ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2778
Mailing Address - Country:US
Mailing Address - Phone:858-939-8350
Mailing Address - Fax:858-939-8360
Practice Address - Street 1:8010 FROST ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2778
Practice Address - Country:US
Practice Address - Phone:858-939-8350
Practice Address - Fax:858-939-8360
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43872208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G438720Medicaid
CAA49485Medicare UPIN
CA00G438720Medicaid