Provider Demographics
NPI:1649212010
Name:MANIQUIS, NINA SOCORRO E (MD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:SOCORRO E
Last Name:MANIQUIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E PARK AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2898
Mailing Address - Country:US
Mailing Address - Phone:847-522-7505
Mailing Address - Fax:847-522-7504
Practice Address - Street 1:303 E PARK AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2898
Practice Address - Country:US
Practice Address - Phone:847-522-7505
Practice Address - Fax:847-522-7504
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089901207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089901Medicaid
IL036089901Medicaid