Provider Demographics
NPI:1245257062
Name:MANRIQUE, LUIS A (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:MANRIQUE
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 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-5518
Mailing Address - Fax:630-933-4168
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-5518
Practice Address - Fax:630-933-4168
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110692207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4748OtherMEDICARE RAILROAD (GROUP)
P00924096OtherMEDICARE RAILROAD (PROVIDER)
T01421OtherMEDICARE PTAN (INDIVIDUAL)
IL036110692Medicaid
206147OtherMEDICARE PTAN (GROUP)
ILI17153Medicare UPIN