=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386031268
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID MANISCALCO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2015
-----------------------------------------------------
Last Update Date | 09/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3883 AIRWAY DR STE 130
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95403-1671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-521-7999
-----------------------------------------------------
Fax | 707-521-7703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 DISTEL CIR
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94022-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-521-7999
-----------------------------------------------------
Fax | 707-521-7703
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 1162306
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------