Provider Demographics
NPI:1528192218
Name:MANCHIO, JEFFREY VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:VINCENT
Last Name:MANCHIO
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 1:9155 SW BARNES RD STE 231
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6653
Mailing Address - Country:US
Mailing Address - Phone:971-254-9884
Mailing Address - Fax:503-206-8365
Practice Address - Street 1:9155 SW BARNES RD STE 231
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6653
Practice Address - Country:US
Practice Address - Phone:971-254-9884
Practice Address - Fax:503-206-8365
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086125208600000X, 208C00000X
ORMD170539208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN240000389Medicare PIN