Provider Demographics
NPI:1629125877
Name:MANNINO, GERARD JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:JOSEPH
Last Name:MANNINO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 OLD BRIDGE RD
Mailing Address - Street 2:SUITE GH
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5262
Mailing Address - Country:US
Mailing Address - Phone:703-490-4242
Mailing Address - Fax:703-491-6370
Practice Address - Street 1:3302 OLD BRIDGE RD
Practice Address - Street 2:SUITE GH
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5262
Practice Address - Country:US
Practice Address - Phone:703-490-4242
Practice Address - Fax:703-491-6370
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000675111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT21935Medicare UPIN