Provider Demographics
NPI:1609969732
Name:MANNING, IRVIN RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:IRVIN
Middle Name:RANDOLPH
Last Name:MANNING
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 1:617 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3159
Mailing Address - Country:US
Mailing Address - Phone:601-850-8050
Mailing Address - Fax:
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-862-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15926207L00000X
FLME114277207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119622Medicaid
MS00119622Medicaid