Provider Demographics
NPI:1326098534
Name:FIDEL, MANOLITO B (MD)
Entity Type:Individual
Prefix:
First Name:MANOLITO
Middle Name:B
Last Name:FIDEL
Suffix:
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 1:28919 COVECREST DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-4703
Mailing Address - Country:US
Mailing Address - Phone:424-400-7748
Mailing Address - Fax:424-400-7749
Practice Address - Street 1:23700 CAMINO DEL SOL
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5017
Practice Address - Country:US
Practice Address - Phone:310-530-1151
Practice Address - Fax:424-400-7749
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA819092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A819090Medicaid
CA00A819090OtherBLUE SHIELD
H82216Medicare UPIN
CA00A819090Medicaid
CA00A819090OtherBLUE SHIELD
CAA81909BMedicare ID - Type Unspecified