Provider Demographics
NPI:1386648103
Name:MANZO, DAVID LUIGI (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LUIGI
Last Name:MANZO
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 1:621 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2201
Mailing Address - Country:US
Mailing Address - Phone:248-541-4200
Mailing Address - Fax:248-541-4969
Practice Address - Street 1:621 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2201
Practice Address - Country:US
Practice Address - Phone:248-541-4200
Practice Address - Fax:248-541-4969
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDM048656207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4113369OtherAETNA
MI4229975 TYPE 10Medicaid
MIF01746Medicare UPIN
MI4229975 TYPE 10Medicaid