Provider Demographics
NPI:1689650376
Name:DORNA-PESQUERA, MANUEL A (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:DORNA-PESQUERA
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:135 COMMONWEALTH DR. STE. 100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6940
Practice Address - Country:US
Practice Address - Phone:864-263-4444
Practice Address - Fax:864-263-4445
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC194140Medicaid
SCP01195502OtherRAILROAD MEDICARE
SCSC74218157Medicare PIN
G66243Medicare UPIN
SCP01195502OtherRAILROAD MEDICARE
SCP01195502OtherRAILROAD MEDICARE
SCG662435213Medicare PIN
SCG662434722Medicare PIN