Provider Demographics
NPI:1083605364
Name:MANALO, MANOLO M (MD)
Entity Type:Individual
Prefix:
First Name:MANOLO
Middle Name:M
Last Name:MANALO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:2516 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1608
Practice Address - Country:US
Practice Address - Phone:260-471-7197
Practice Address - Fax:260-471-7408
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2020-10-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01041487A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000091895OtherBLUE CROSS BLUE SHIELD
IN100326320Medicaid
INP00970644OtherRAILROAD MEDICARE
INM400048072Medicare PIN
IN100326320Medicaid
000000000303OtherMPLAN
IN925500QMedicare PIN
IN080122016OtherRAILROAD MEDICARE
IN100326320Medicaid
INM400048072Medicare PIN