Provider Demographics
NPI:1316026974
Name:MANZANILLA, RAINIER A (MD)
Entity Type:Individual
Prefix:
First Name:RAINIER
Middle Name:A
Last Name:MANZANILLA
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 1:1701 E CESAR E CHAVEZ AVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2464
Mailing Address - Country:US
Mailing Address - Phone:323-441-1122
Mailing Address - Fax:323-441-1172
Practice Address - Street 1:1701 E CESAR E CHAVEZ AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2464
Practice Address - Country:US
Practice Address - Phone:323-441-1122
Practice Address - Fax:323-441-1172
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61710207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG61710EMedicare PIN
CAE10433Medicare UPIN