Provider Demographics
NPI:1093707978
Name:MANJARREZ, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MANJARREZ
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 1:702 WAKE AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-7502
Mailing Address - Country:US
Mailing Address - Phone:760-352-7216
Mailing Address - Fax:760-352-1028
Practice Address - Street 1:702 WAKE AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-7502
Practice Address - Country:US
Practice Address - Phone:760-352-7216
Practice Address - Fax:760-352-1028
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
173000000X
CAA538322080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA53832OtherMEDICAL LICENSE