Provider Demographics
NPI:1477523447
Name:MANUSOV, ERON GRANT (MD)
Entity Type:Individual
Prefix:
First Name:ERON
Middle Name:GRANT
Last Name:MANUSOV
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 1:2102 TREASURE HILLS BLVD., #1.326
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550
Mailing Address - Country:US
Mailing Address - Phone:956-296-1519
Mailing Address - Fax:956-296-1331
Practice Address - Street 1:2106 TREASURE HILLS BLVD # 1.326
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8736
Practice Address - Country:US
Practice Address - Phone:956-296-1519
Practice Address - Fax:956-296-1331
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87762207QS0010X
FLME105964207QS0010X
NC9800625207QS0010X
TXP8943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX337122104Medicaid
TXH08FR76401OtherBCBS
TX337122105OtherMEDICAID - CSHCN
TX337122101Medicaid
F10612Medicare UPIN
NC03980184Medicare PIN
TX352521YK00Medicare PIN