Healthcare Provider Details

I. General information

NPI: 1245681683
Provider Name (Legal Business Name): JEFFREY MICHAEL MANZANO AQUINO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

124 COLONY PL
MADISON MS
39110
US

V. Phone/Fax

Practice location:
  • Phone: 732-439-8519
  • Fax:
Mailing address:
  • Phone: 732-439-8519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA10601300
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number30124
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: