Provider Demographics
NPI:1457400889
Name:MANOUKIAN, JERRY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:MANOUKIAN
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:PO BOX 2742244
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2244
Mailing Address - Country:US
Mailing Address - Phone:650-940-1006
Mailing Address - Fax:650-940-1008
Practice Address - Street 1:2500 HOSPITAL DR STE 4A
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040
Practice Address - Country:US
Practice Address - Phone:650-940-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64508207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE86734Medicare UPIN
00G645080Medicare ID - Type Unspecified