Provider Demographics
NPI:1205811510
Name:MANNIS, MARK JOEL (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOEL
Last Name:MANNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 Y ST
Mailing Address - Street 2:SUITE 2400
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:916-734-6957
Mailing Address - Fax:916-734-6197
Practice Address - Street 1:4860 Y ST
Practice Address - Street 2:SUITE 2400
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-6957
Practice Address - Fax:916-734-6197
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR002104IMedicaid
CAZZZP3420ZMedicare ID - Type Unspecified
CAA48691Medicare UPIN