Provider Demographics
NPI:1346270063
Name:MANOS, THEODORE ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ANDREW
Last Name:MANOS
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 1:30099 N 129TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-5267
Mailing Address - Country:US
Mailing Address - Phone:928-501-6666
Mailing Address - Fax:928-501-6566
Practice Address - Street 1:8424 E SHEA BLVD
Practice Address - Street 2:STE. 101
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6662
Practice Address - Country:US
Practice Address - Phone:480-256-1520
Practice Address - Fax:480-478-6628
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37050207RG0300X, 208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1015031Medicaid
AZ325833Medicaid
WA1123777Medicaid
AZ325833Medicaid
WA1015031Medicaid
WAG8864457Medicare PIN
WAG8864456Medicare PIN
MA7315OtherB/S REGENCE 90
WA1123777Medicaid
WAG8864457Medicare PIN