Provider Demographics
NPI:1043577000
Name:DATILES, MANUEL J IV (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:J
Last Name:DATILES
Suffix:IV
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 1:5963 EXCHANGE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-9256
Mailing Address - Country:US
Mailing Address - Phone:410-549-0900
Mailing Address - Fax:410-549-6121
Practice Address - Street 1:5963 EXCHANGE DR STE 100
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-9256
Practice Address - Country:US
Practice Address - Phone:410-549-0900
Practice Address - Fax:410-549-6121
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0079527208000000X
DEC10011867208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics