Provider Demographics
NPI:1598903056
Name:MADERA MANZUETA, CARLOS EMILIO (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:EMILIO
Last Name:MADERA MANZUETA
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 1:2205 NEW GARDEN RD
Mailing Address - Street 2:APT. 1707
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-1703
Mailing Address - Country:US
Mailing Address - Phone:336-207-6438
Mailing Address - Fax:
Practice Address - Street 1:1200 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1020
Practice Address - Country:US
Practice Address - Phone:336-832-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC153004207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC153004Medicare UPIN