Provider Demographics
NPI:1225012891
Name:MANZELLA, JOHN R JR (DO)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:MANZELLA
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1353 STATE ROUTE 903
Mailing Address - Street 2:
Mailing Address - City:JIM THORPE
Mailing Address - State:PA
Mailing Address - Zip Code:18229-2734
Mailing Address - Country:US
Mailing Address - Phone:570-325-8393
Mailing Address - Fax:570-325-8029
Practice Address - Street 1:1353 STATE ROUTE 903
Practice Address - Street 2:
Practice Address - City:JIM THORPE
Practice Address - State:PA
Practice Address - Zip Code:18229-2734
Practice Address - Country:US
Practice Address - Phone:570-325-8393
Practice Address - Fax:570-325-8029
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010263L207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0314295000OtherPERSONAL BLUE SHIELD
03197301OtherCAPITAL BLUE CROSS
010054200OtherBLACK LUNG
5389099OtherAETNA
PA001780247Medicaid
PA176513OtherBLUE SHIELD
2968846OtherGHI
20031252OtherAMERIHEALTH MERCY
PAP00600418OtherPALMETTO
1753980OtherFEDERAL BLUE SHIELD
176513OtherAMERIHEALTH ADMIN
PA088593Medicare PIN
G44312Medicare UPIN