Provider Demographics
NPI:1629479209
Name:MANSO, YADIRA
Entity Type:Individual
Prefix:
First Name:YADIRA
Middle Name:
Last Name:MANSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 SW 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3313
Mailing Address - Country:US
Mailing Address - Phone:305-631-5975
Mailing Address - Fax:305-644-6407
Practice Address - Street 1:11501 SW 40TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3313
Practice Address - Country:US
Practice Address - Phone:305-631-5975
Practice Address - Fax:305-644-6407
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL121280207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine