Provider Demographics
NPI:1891229472
Name:MANJARREZ, NICHOLAS (IDC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:MANJARREZ
Suffix:
Gender:M
Credentials:IDC
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 159
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5159
Mailing Address - Country:US
Mailing Address - Phone:860-694-6453
Mailing Address - Fax:
Practice Address - Street 1:159 TROUT AVENUE
Practice Address - Street 2:NAVAL UNDERSEA MEDICAL INSTITUTE
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5159
Practice Address - Country:US
Practice Address - Phone:860-694-2876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman