Provider Demographics
NPI:1811026297
Name:MANSHIO, DENNIS TAKAMI (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:TAKAMI
Last Name:MANSHIO
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 1:2907 S WABASH AVE STE 100A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3271
Mailing Address - Country:US
Mailing Address - Phone:773-477-3699
Mailing Address - Fax:773-477-0624
Practice Address - Street 1:2907 S WABASH AVE STE 100A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3271
Practice Address - Country:US
Practice Address - Phone:773-477-3699
Practice Address - Fax:312-877-5049
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065850Medicaid
583020Medicare ID - Type Unspecified