Provider Demographics
NPI:1518965318
Name:MANTONYA, JERRY ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALLEN
Last Name:MANTONYA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2919
Mailing Address - Country:US
Mailing Address - Phone:740-366-6601
Mailing Address - Fax:740-366-6286
Practice Address - Street 1:919 N 21ST ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2919
Practice Address - Country:US
Practice Address - Phone:740-366-6601
Practice Address - Fax:740-366-6286
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310811048029OtherCARESOURCE
OH0186883Medicaid
OH000000117115OtherANTHEM BC/BS
OH310811048029OtherCARESOURCE
OH000000117115OtherANTHEM BC/BS
OHT46506Medicare UPIN