Provider Demographics
NPI:1649205329
Name:MANZIELLO, BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:MANZIELLO
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86302-0150
Mailing Address - Country:US
Mailing Address - Phone:928-445-4860
Mailing Address - Fax:928-776-6084
Practice Address - Street 1:NORTHERN ARIZONA VA HEALTH CARE SYSTEM
Practice Address - Street 2:5000 N. HIGHWAY 89
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86313
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:928-776-6084
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127042207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine