Provider Demographics
NPI:1720643091
Name:MANAKHIMOV, ISAAC
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:MANAKHIMOV
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 1:1034 GATEWAY BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-8360
Mailing Address - Country:US
Mailing Address - Phone:561-503-4412
Mailing Address - Fax:
Practice Address - Street 1:1034 GATEWAY BLVD STE 106
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8360
Practice Address - Country:US
Practice Address - Phone:561-503-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO7079156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty