Provider Demographics
NPI:1124006259
Name:MANZANO, VICKI (DO)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:MANZANO
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 1:2154 COMMONS PKWY
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3986
Mailing Address - Country:US
Mailing Address - Phone:517-706-0444
Mailing Address - Fax:
Practice Address - Street 1:2154 COMMONS PKWY
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3986
Practice Address - Country:US
Practice Address - Phone:517-706-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0100575OtherPHYSICIANS HEALTH PLAN
MIE50170OtherHEALTH NET FEDERAL SERVIC
MI202330OtherHEALTH ADVANTAGE
MI3424975Medicaid
MI202330OtherMCLAREN HEALTH PLAN
MI5768069OtherAETNA
MI202330OtherMCLAREN HEALTH PLAN
MIE50170OtherHEALTH NET FEDERAL SERVIC