Provider Demographics
NPI:1235429457
Name:MANZLAK, DERRICK ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:ANTHONY
Last Name:MANZLAK
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 1:3976 UNIVERSITY LAKE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4644
Mailing Address - Country:US
Mailing Address - Phone:907-729-8141
Mailing Address - Fax:907-729-3998
Practice Address - Street 1:3976 UNIVERSITY LAKE DR STE 100
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4644
Practice Address - Country:US
Practice Address - Phone:907-729-8141
Practice Address - Fax:907-729-3998
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2617282084P0800X
VA01012626282084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1235429457Medicaid