Healthcare Provider Details

I. General information

NPI: 1578577425
Provider Name (Legal Business Name): JOSEPH MANNO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 SUMMIT AVE
HACKENSACK NJ
07601-1262
US

IV. Provider business mailing address

83 SUMMIT AVE
HACKENSACK NJ
07601-1262
US

V. Phone/Fax

Practice location:
  • Phone: 201-646-0010
  • Fax: 201-646-0600
Mailing address:
  • Phone: 201-646-0010
  • Fax: 201-646-0600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MA04316700
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1253506
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: