Provider Demographics
NPI:1811026297
Name:MANSHIO, DENNIS TAKAMI (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:TAKAMI
Last Name:MANSHIO
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 1:1132 W WRIGHTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1315
Mailing Address - Country:US
Mailing Address - Phone:773-477-3699
Mailing Address - Fax:773-477-0624
Practice Address - Street 1:945 W GEORGE ST
Practice Address - Street 2:SUITE 218
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5893
Practice Address - Country:US
Practice Address - Phone:773-477-3699
Practice Address - Fax:773-477-0624
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D11998Medicare UPIN
583020Medicare ID - Type Unspecified