Provider Demographics
NPI:1881682235
Name:MANIS, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MANIS
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:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:LOCKESBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71846-0295
Mailing Address - Country:US
Mailing Address - Phone:870-289-5865
Mailing Address - Fax:870-289-6993
Practice Address - Street 1:400 CRESTWOOD CIR
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-5512
Practice Address - Country:US
Practice Address - Phone:479-394-3887
Practice Address - Fax:479-394-7758
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR12711000000OtherQUALCHOICE
AR53296OtherBCBS
AR102561001Medicaid
AR53296Medicare PIN
AR53296OtherBCBS