Provider Demographics
NPI:1851351274
Name:MANLEY, JACK C (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:MANLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:C
Other - Last Name:MANLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:201 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4216
Mailing Address - Country:US
Mailing Address - Phone:414-259-7505
Mailing Address - Fax:414-259-7583
Practice Address - Street 1:201 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4216
Practice Address - Country:US
Practice Address - Phone:414-259-7505
Practice Address - Fax:414-259-7583
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13968207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30897900Medicaid
WI30897900Medicaid
023650007Medicare ID - Type Unspecified