Provider Demographics
NPI:1861561136
Name:MANNING, BRUCE L (OD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:MANNING
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:665 BRIARTHORN CRESCENT DR.
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-7501
Practice Address - Country:US
Practice Address - Phone:330-336-9177
Practice Address - Fax:330-335-3318
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.003551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0487567Medicaid
OH0487567Medicaid
OH0487567Medicaid
OHT47623Medicare UPIN
OH34-1364551OtherEIN