Provider Demographics
NPI:1053376756
Name:LONGO-LLENIN, MANUEL A (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:LONGO-LLENIN
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 1:3536 N FEDERAL HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-6264
Mailing Address - Country:US
Mailing Address - Phone:954-580-8838
Mailing Address - Fax:954-580-8839
Practice Address - Street 1:2964 N STATE ROAD 7
Practice Address - Street 2:SUITE 206
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063
Practice Address - Country:US
Practice Address - Phone:954-580-8838
Practice Address - Fax:954-580-8839
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83303207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264383900Medicaid
FL17468YMedicare ID - Type Unspecified
FL264383900Medicaid