Provider Demographics
NPI:1215040084
Name:MANZANO, LEANDER ENRIQUEZ (MD)
Entity Type:Individual
Prefix:
First Name:LEANDER
Middle Name:ENRIQUEZ
Last Name:MANZANO
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 1:8902 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6401
Mailing Address - Country:US
Mailing Address - Phone:818-830-7033
Mailing Address - Fax:818-830-7280
Practice Address - Street 1:8902 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:ARLETA
Practice Address - State:CA
Practice Address - Zip Code:91331-6401
Practice Address - Country:US
Practice Address - Phone:818-830-7033
Practice Address - Fax:818-830-7280
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP70468FOtherCDC GRP #
CAFHC70468FMedicaid
CAHAP70468FOtherFAMILY PLANNING GRP #
CAW11570Medicare ID - Type UnspecifiedMEDICARE GR #
CAHAP70468FOtherFAMILY PLANNING GRP #
CAWA67142AMedicare ID - Type UnspecifiedMEDICARE #