Provider Demographics
NPI:1417041013
Name:MANCHENO, MARIO ANIBAL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ANIBAL
Last Name:MANCHENO
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 1:422 GRAND STREET
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030
Mailing Address - Country:US
Mailing Address - Phone:201-656-8743
Mailing Address - Fax:201-319-0867
Practice Address - Street 1:422 GRAND STREET
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030
Practice Address - Country:US
Practice Address - Phone:201-656-8743
Practice Address - Fax:201-319-0867
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03336800208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3939707Medicaid
C07940Medicare UPIN
NJMA521048Medicare ID - Type Unspecified