Provider Demographics
NPI:1861476145
Name:MANESS, ELLIOT CHARLES (DO)
Entity Type:Individual
Prefix:MR
First Name:ELLIOT
Middle Name:CHARLES
Last Name:MANESS
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 1:2755 SILVER CREEK RD STE 111
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8343
Mailing Address - Country:US
Mailing Address - Phone:928-704-7163
Mailing Address - Fax:928-444-1326
Practice Address - Street 1:2755 SILVER CREEK RD STE 111
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8343
Practice Address - Country:US
Practice Address - Phone:928-704-7163
Practice Address - Fax:928-444-1326
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3609208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G54837Medicare UPIN
63606Medicare ID - Type Unspecified