Provider Demographics
NPI:1134391030
Name:JERRY MANOUKIAN M.D. A MEDICAL CORPORATION
Entity type:Organization
Organization Name:JERRY MANOUKIAN M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MANOUKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-940-1006
Mailing Address - Street 1:2500 HOSPITAL DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4106
Mailing Address - Country:US
Mailing Address - Phone:650-940-1006
Mailing Address - Fax:650-940-1008
Practice Address - Street 1:2500 HOSPITAL DR
Practice Address - Street 2:SUITE 4
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4106
Practice Address - Country:US
Practice Address - Phone:650-940-1006
Practice Address - Fax:650-940-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64508261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG85843Medicare UPIN
CAE86734Medicare UPIN