Provider Demographics
NPI:1164863734
Name:MANNING, JUSTIN LEONARD (OD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEONARD
Last Name:MANNING
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9205 N UNION BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7830
Mailing Address - Country:US
Mailing Address - Phone:719-282-0400
Mailing Address - Fax:719-282-1004
Practice Address - Street 1:9205 N UNION BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7830
Practice Address - Country:US
Practice Address - Phone:719-282-0400
Practice Address - Fax:719-282-1004
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60378496152W00000X
CO00003278152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1164863734Medicaid
WA1164863734Medicaid