Provider Demographics
NPI:1669534137
Name:MANN, ROBERT E
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:MANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 NE 44TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-1437
Mailing Address - Country:US
Mailing Address - Phone:954-776-0363
Mailing Address - Fax:
Practice Address - Street 1:23 NE 44TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-1437
Practice Address - Country:US
Practice Address - Phone:954-776-0363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1603156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086606700Medicaid
FL59-2299228OtherTAX ID
FL086606700Medicaid