Provider Demographics
NPI:1275882904
Name:MANUEL J BACALLAO M.D., L.L.C.
Entity Type:Organization
Organization Name:MANUEL J BACALLAO M.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BACALLAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-279-7446
Mailing Address - Street 1:8525 SW 92ND ST
Mailing Address - Street 2:SUITE B-4
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7365
Mailing Address - Country:US
Mailing Address - Phone:305-279-7446
Mailing Address - Fax:305-598-8753
Practice Address - Street 1:8525 SW 92ND ST
Practice Address - Street 2:SUITE B-4
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7365
Practice Address - Country:US
Practice Address - Phone:305-279-7446
Practice Address - Fax:305-598-8753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD77138Medicare UPIN