Provider Demographics
NPI:1114981024
Name:MANUEL, ERNESTO (MD)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:MANUEL
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 1:396 DINGESS ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3624
Mailing Address - Country:US
Mailing Address - Phone:304-831-1700
Mailing Address - Fax:304-831-1726
Practice Address - Street 1:396 DINGESS ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3624
Practice Address - Country:US
Practice Address - Phone:304-831-1700
Practice Address - Fax:304-831-1726
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0057545000Medicaid
WVD49507Medicare UPIN
WVMA7314751Medicare ID - Type Unspecified