Provider Demographics
NPI:1578653085
Name:MANCHESTER, MARK G (CO2015)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:MANCHESTER
Suffix:
Gender:M
Credentials:CO2015
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-5115
Mailing Address - Country:US
Mailing Address - Phone:845-343-7337
Mailing Address - Fax:845-343-1710
Practice Address - Street 1:1 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-5115
Practice Address - Country:US
Practice Address - Phone:845-343-7337
Practice Address - Fax:845-343-1710
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00368350Medicaid
NY00368350Medicaid