Provider Demographics
NPI:1235573148
Name:MANWARING, JARED K (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:K
Last Name:MANWARING
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 1:2375 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7407
Mailing Address - Country:US
Mailing Address - Phone:208-552-1234
Mailing Address - Fax:
Practice Address - Street 1:2375 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-552-1234
Practice Address - Fax:208-529-1948
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14260208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty