Provider Demographics
NPI:1407848971
Name:MANZER, JONATHAN LYLE (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LYLE
Last Name:MANZER
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 1:3071 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-7851
Mailing Address - Country:US
Mailing Address - Phone:417-358-4811
Mailing Address - Fax:417-358-4781
Practice Address - Street 1:3071 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-7851
Practice Address - Country:US
Practice Address - Phone:417-358-4811
Practice Address - Fax:417-358-4781
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209288406Medicaid
MO000014211Medicare ID - Type Unspecified
MOI08912Medicare UPIN