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General NPI Number Information
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NPI Number | 1407848971
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Entity Type | Individual
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Provider Name | JONATHAN LYLE MANZER M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/19/2005
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Last Update Date | 09/16/2013
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Provider Practice Location Address
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Address Line | 3071 S GRAND AVE
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City | CARTHAGE
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State | MO
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Zip | 64836-7851
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Country | US
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Telephone | 417-358-4811
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Fax | 417-358-4781
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Provider Business Mailing Address
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Address Line | 3071 S GRAND AVE
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City | CARTHAGE
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State | MO
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Zip | 64836-7851
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Country | US
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Telephone | 417-358-4811
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Fax | 417-358-4781
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2004001464
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License Number State | MO
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