Provider Demographics
NPI:1235132648
Name:MANUBAY, TERESITA I (MD)
Entity Type:Individual
Prefix:
First Name:TERESITA
Middle Name:I
Last Name:MANUBAY
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 1:1312 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2526
Mailing Address - Country:US
Mailing Address - Phone:573-888-1224
Mailing Address - Fax:573-888-3046
Practice Address - Street 1:1312 1ST ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2526
Practice Address - Country:US
Practice Address - Phone:573-888-1224
Practice Address - Fax:573-888-3046
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR6794208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
A12039Medicare UPIN
9798Medicare ID - Type Unspecified