Provider Demographics
NPI:1396835104
Name:MANSHARDT, JAMES ROGER (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROGER
Last Name:MANSHARDT
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:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-0295
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 PAPPAS ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-1701
Practice Address - Country:US
Practice Address - Phone:956-794-3000
Practice Address - Fax:956-794-3301
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD60762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD6076OtherTEXAS MEDICAL BOARD