Provider Demographics
NPI:1245443548
Name:SAN, MANUEL LE-YENG (DO)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:LE-YENG
Last Name:SAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 CORONA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2582
Mailing Address - Country:US
Mailing Address - Phone:573-234-1800
Mailing Address - Fax:573-234-1799
Practice Address - Street 1:2101 CORONA RD STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2582
Practice Address - Country:US
Practice Address - Phone:573-234-1800
Practice Address - Fax:573-234-1799
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006029319207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1245443548Medicaid
MOP00770996OtherRR MEDICARE PTAN
MO207024605Medicaid
MO118080034Medicare PIN
MOP00770996OtherRR MEDICARE PTAN