Provider Demographics
NPI:1295714020
Name:MANNA, MARIO JOSEPH (DO)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:JOSEPH
Last Name:MANNA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 090965
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-0965
Mailing Address - Country:US
Mailing Address - Phone:718-630-1404
Mailing Address - Fax:718-630-1406
Practice Address - Street 1:7318 13TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-2011
Practice Address - Country:US
Practice Address - Phone:718-630-1404
Practice Address - Fax:718-630-1406
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223184207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02439632Medicaid
NY5154B1Medicare ID - Type Unspecified
NY02439632Medicaid