Provider Demographics
NPI:1689712408
Name:MANZO, WILLIAM A (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:MANZO
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 1:1111 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-2613
Mailing Address - Country:US
Mailing Address - Phone:515-643-2667
Mailing Address - Fax:
Practice Address - Street 1:1111 6TH AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2613
Practice Address - Country:US
Practice Address - Phone:515-643-2667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA4537102085R0202X
IL0361363022085R0202X
MO1134812085R0202X
AR36052085R0202X
CAG769742085R0202X
IA464682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR98374OtherARK BLUE SHIELD
MO208856120Medicaid
AR139978001Medicaid
MO173098OtherMO BLUE SHIELD
MO208856120Medicaid
AR98374OtherARK BLUE SHIELD