Provider Demographics
NPI:1831320621
Name:MANJARREZ, LISETH (MD)
Entity Type:Individual
Prefix:DR
First Name:LISETH
Middle Name:
Last Name:MANJARREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 W CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2376
Mailing Address - Country:US
Mailing Address - Phone:847-342-1554
Mailing Address - Fax:847-342-1711
Practice Address - Street 1:675 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2376
Practice Address - Country:US
Practice Address - Phone:847-342-1554
Practice Address - Fax:847-342-1711
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094777208000000X
IL036.130521208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics