Provider Demographics
NPI:1962497628
Name:MANJON, JOSE M (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:M
Last Name:MANJON
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 1:4300 LONDONDERRY RD STE 305
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-5317
Mailing Address - Country:US
Mailing Address - Phone:717-791-2960
Mailing Address - Fax:717-791-2961
Practice Address - Street 1:4300 LONDONDERRY RD STE 305
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5317
Practice Address - Country:US
Practice Address - Phone:717-724-6788
Practice Address - Fax:717-730-0099
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035254E207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001057812Medicaid
PA001057812Medicaid
PA192960Medicare PIN