MEDICARE: ELIZABETH MANNINO M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A43914	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W14158	OTHER	CA	GROUP PTAN
2	ZZZ20041Z	OTHER	CA	GROUP PTAN

General Provider Information

NPI Number	:	1548290463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH MANNINO M.D

Provider Business Mailing Address
First Line	:	425 N DATE ST
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-3413
Country	:	US
Telephone Number	:	760-737-2035
Fax Number	:	760-741-2782

Provider Business Practice Location Address
First Line	:	10039 VINE ST
Second Line	:
City	:	LAKESIDE
State	:	CA
Zip	:	92040-3130
Country	:	US
Telephone Number	:	619-390-9975
Fax Number	:	619-390-8721

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	05/03/2012

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