Provider Demographics
NPI:1700849072
Name:MANNINO, ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:MANNINO
Suffix:
Gender:M
Credentials:DO
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 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9879
Mailing Address - Fax:928-522-9880
Practice Address - Street 1:126 E MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541
Practice Address - Country:US
Practice Address - Phone:928-468-8610
Practice Address - Fax:928-468-8605
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDO02797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ133760Medicaid
AZ0856210OtherBLUE CROSS BLUE SHIELD
AZ0856210OtherBLUE CROSS BLUE SHIELD
AZ0856210OtherBLUE CROSS BLUE SHIELD