Healthcare Provider Details

I. General information

NPI: 1700849072
Provider Name (Legal Business Name): ANTHONY MANNINO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E MAIN ST STE B
PAYSON AZ
85541
US

IV. Provider business mailing address

PO BOX 3630
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-468-8610
  • Fax: 928-468-8605
Mailing address:
  • Phone: 928-522-9879
  • Fax: 928-522-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO02797
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: