MEDICARE: DR. JOHN A MANNIK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901003263	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003814500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN A MANNIK O.D.

Provider Business Mailing Address
First Line	:	1088 S BAILEY AVE
Second Line	:	SUITE B
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090-9728
Country	:	US
Telephone Number	:	269-637-1442
Fax Number	:	269-637-3801

Provider Business Practice Location Address
First Line	:	1088 S BAILEY AVE
Second Line	:	SUITE B
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090-9728
Country	:	US
Telephone Number	:	269-637-1442
Fax Number	:	269-637-3801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	02/19/2015

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Directions to “ DR. JOHN A MANNIK O.D.” Practice Location

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