Provider Demographics
NPI:1124183702
Name:MANNOS, JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MANNOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702
Mailing Address - Country:US
Mailing Address - Phone:330-452-3200
Mailing Address - Fax:330-452-5508
Practice Address - Street 1:333 2ND ST SE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702
Practice Address - Country:US
Practice Address - Phone:330-452-3200
Practice Address - Fax:330-452-5508
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006268M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH085390OtherMEDICARE PTAN CHANGED TO H085390
OH2089243Medicaid
G91045Medicare UPIN
OH0868211Medicare ID - Type Unspecified