Basic Information
| Provider Information | |||||||||
| NPI: | 1609969732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | IRVIN | ||||||||
| MiddleName: | RANDOLPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 617 MAGNOLIA DR | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325413159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018508050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508621111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 15926 | MS | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME114277 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00119622 | 05 | MS | MEDICAID |