Provider Demographics
NPI:1295047850
Name:MANZANO, GONZALO ANDRES (MD)
Entity type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:ANDRES
Last Name:MANZANO
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 1:211 CAROL AVE
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3415 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2403
Practice Address - Country:US
Practice Address - Phone:718-741-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-11
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263140208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics