Provider Demographics
NPI:1114074044
Name:MANNINEN, CYNTHIA A (DO)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:MANNINEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E 3RD ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5728
Mailing Address - Country:US
Mailing Address - Phone:970-764-1790
Mailing Address - Fax:970-375-7927
Practice Address - Street 1:810 E 3RD ST
Practice Address - Street 2:SUITE 201
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5728
Practice Address - Country:US
Practice Address - Phone:970-764-1790
Practice Address - Fax:970-375-7927
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008368207Q00000X
CODR.0051108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4961694Medicaid
NM51722585Medicaid
AZ839761Medicaid
UT1114074044Medicaid
CO43101852Medicaid
CO43101852Medicaid
F16414Medicare UPIN
MI0Z56005017Medicare PIN