Provider Demographics
NPI:1346243904
Name:MANIFOLD, REX E (MD)
Entity Type:Individual
Prefix:DR
First Name:REX
Middle Name:E
Last Name:MANIFOLD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1720 LOUISIANA BLVD NE
Mailing Address - Street 2:STE 401
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7020
Mailing Address - Country:US
Mailing Address - Phone:505-260-4300
Mailing Address - Fax:505-260-4338
Practice Address - Street 1:1100 CENTRAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4930
Practice Address - Country:US
Practice Address - Phone:505-841-1234
Practice Address - Fax:505-841-1956
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM87-264207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM961268OtherPRONET / AETNA
NM19959Medicaid
NMNM009G14OtherBLUE CROSS BLUE SHEILD
CO59276703Medicaid
VA5707722Medicaid
AZ268153Medicaid
NM39289Medicaid
NMNM009G14OtherBLUE CROSS BLUE SHEILD