Provider Demographics
NPI:1154470136
Name:MANRIQUE, MARIEVIC G (MD)
Entity Type:Individual
Prefix:
First Name:MARIEVIC
Middle Name:G
Last Name:MANRIQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 V ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1460
Mailing Address - Country:US
Mailing Address - Phone:916-734-5028
Mailing Address - Fax:916-734-2975
Practice Address - Street 1:4150 V ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1460
Practice Address - Country:US
Practice Address - Phone:916-734-5028
Practice Address - Fax:916-734-2975
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2020-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73943207LC0200X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051520267Medicaid
AL051520267OtherBCBS PROVIDER NUMBER
H66294Medicare UPIN
AL051520267Medicare ID - Type UnspecifiedPROVIDER NUMBER