Provider Demographics
NPI:1912900010
Name:MANFREDI, PHILIP DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:DANIEL
Last Name:MANFREDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8042 WURZBACH RD
Mailing Address - Street 2:STE 480
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3808
Mailing Address - Country:US
Mailing Address - Phone:210-614-3964
Mailing Address - Fax:210-614-3971
Practice Address - Street 1:8042 WURZBACH RD
Practice Address - Street 2:STE 480
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3808
Practice Address - Country:US
Practice Address - Phone:210-614-3964
Practice Address - Fax:210-614-3971
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9224208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0894701-01Medicaid
TXB24601Medicare UPIN
TX00M939Medicare ID - Type Unspecified