Provider Demographics
NPI:1124018189
Name:AGUILA-MANALO, MARISA S (MD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:S
Last Name:AGUILA-MANALO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3714
Mailing Address - Country:US
Mailing Address - Phone:773-467-9925
Mailing Address - Fax:773-467-9938
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3714
Practice Address - Country:US
Practice Address - Phone:773-467-9925
Practice Address - Fax:773-467-9938
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068818208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632143OtherBCBS
IL036068818Medicaid
IL01632143OtherBCBS