Provider Demographics
NPI:1720043599
Name:JOEL, MANNIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MANNIE
Middle Name:
Last Name:JOEL
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 1:15035 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1901
Mailing Address - Country:US
Mailing Address - Phone:510-278-0226
Mailing Address - Fax:510-278-5054
Practice Address - Street 1:15035 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1901
Practice Address - Country:US
Practice Address - Phone:510-278-0226
Practice Address - Fax:510-278-5054
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34460174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27487Medicare UPIN