Provider Demographics
NPI:1225080203
Name:CASANOVA, MANUAL A (MD)
Entity Type:Individual
Prefix:
First Name:MANUAL
Middle Name:A
Last Name:CASANOVA
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-441-1934
Mailing Address - Fax:740-446-5982
Practice Address - Street 1:90 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5709
Practice Address - Fax:740-446-5697
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-18982085R0202X
WV152472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000193267OtherUNISON MEDICAID
WV0118150000Medicaid
000000007167OtherANTHEM BCBS
001714053OtherMOUNTAIN STATE BCBS
OH0465296OtherMOLINA MEDICAID
300028173OtherRR MEDICARE
300028173OtherRR MEDICARE
OH0798364Medicare PIN
000000007167OtherANTHEM BCBS
001714053OtherMOUNTAIN STATE BCBS