Healthcare Provider Details

I. General information

NPI: 1548290463
Provider Name (Legal Business Name): ELIZABETH MANNINO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10039 VINE ST
LAKESIDE CA
92040-3130
US

IV. Provider business mailing address

425 N DATE ST
ESCONDIDO CA
92025-3413
US

V. Phone/Fax

Practice location:
  • Phone: 619-390-9975
  • Fax: 619-390-8721
Mailing address:
  • Phone: 760-737-2035
  • Fax: 760-741-2782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA43914
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: