Basic Information
Provider Information
NPI: 1366735243
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MANRY
FirstName: MATTHEW
MiddleName: WILLIAM
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1945 CEI DR
Address2:  
City: BLUE ASH
State: OH
PostalCode: 452425664
CountryCode: US
TelephoneNumber: 5135693741
FaxNumber: 5135693941
Practice Location
Address1: 1400 DRY CREEK DR
Address2:  
City: LONGMONT
State: CO
PostalCode: 80503
CountryCode: US
TelephoneNumber: 3037723300
FaxNumber: 3036823380
Other Information
ProviderEnumerationDate: 05/25/2011
LastUpdateDate: 07/31/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207WX0107XDR.0060309COY    

ID Information
IDTypeStateIssuerDescription
900016377405CO MEDICAID


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