Healthcare Provider Details

I. General information

NPI: 1811026297
Provider Name (Legal Business Name): DENNIS TAKAMI MANSHIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2007
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2907 S WABASH AVE STE 100A
CHICAGO IL
60616-3271
US

IV. Provider business mailing address

2907 S WABASH AVE STE 100A
CHICAGO IL
60616-3271
US

V. Phone/Fax

Practice location:
  • Phone: 773-477-3699
  • Fax: 312-877-5049
Mailing address:
  • Phone: 773-477-3699
  • Fax: 773-477-0624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036065850
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: