Healthcare Provider Details

I. General information

NPI: 1710419122
Provider Name (Legal Business Name): RICHARD ALEXANDER MANFREADY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 S HACKETT RD
WATERLOO IA
50701-3500
US

IV. Provider business mailing address

PO BOX 2758
WATERLOO IA
50704-2758
US

V. Phone/Fax

Practice location:
  • Phone: 319-234-5990
  • Fax: 319-234-5994
Mailing address:
  • Phone: 319-235-5390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036.152697
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD-51934
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: