Provider Demographics
NPI:1487648937
Name:MANOS, TED E (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:E
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 1:16140 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-0210
Mailing Address - Country:US
Mailing Address - Phone:352-589-6424
Mailing Address - Fax:
Practice Address - Street 1:249 E COLLINS ST
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:FL
Practice Address - Zip Code:32784-8383
Practice Address - Country:US
Practice Address - Phone:352-771-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2013-01-14
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
FLME0027734174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049224800Medicaid
FLD57039Medicare UPIN
FLP00028050Medicare ID - Type UnspecifiedRAILROAD MEDICARE PROV #
FL049224800Medicaid