Provider Demographics
NPI:1326144601
Name:ESTIOKO, MANUEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:R
Last Name:ESTIOKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1328 22ND STREET
Mailing Address - Street 2:SAINT JOHNS HEALTH CENTER
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-829-8618
Mailing Address - Fax:310-829-8607
Practice Address - Street 1:1328 22ND STREET
Practice Address - Street 2:SAINT JOHNS HEALTH CENTER
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-829-8618
Practice Address - Fax:310-829-8607
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42790208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WC42790BMedicare ID - Type Unspecified
C08368Medicare UPIN