Provider Demographics
NPI:1588809420
Name:MANUEL, VLADIMIR (MD)
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:
Last Name:MANUEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-5138
Mailing Address - Fax:
Practice Address - Street 1:4560 ADMIRALTY WAY STE 100
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5424
Practice Address - Country:US
Practice Address - Phone:310-827-3700
Practice Address - Fax:310-578-5379
Is Sole Proprietor?:No
Enumeration Date:2008-12-05
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA108725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14560AOtherPTAN NUMBER