Provider Demographics
NPI:1568523819
Name:MANNARD, ENN (MD)
Entity Type:Individual
Prefix:DR
First Name:ENN
Middle Name:
Last Name:MANNARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:DRAGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3285 FLORA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6004
Mailing Address - Country:US
Mailing Address - Phone:805-544-2951
Mailing Address - Fax:805-781-1265
Practice Address - Street 1:1989 VICENTE DR
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6863
Practice Address - Country:US
Practice Address - Phone:805-781-4179
Practice Address - Fax:805-781-1265
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC0363262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA36228Medicare UPIN