Provider Demographics
NPI:1518971845
Name:MANATU, BERNARD (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:MANATU
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:PO BOX 664
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-0664
Mailing Address - Country:US
Mailing Address - Phone:276-524-1785
Mailing Address - Fax:276-524-1787
Practice Address - Street 1:320 CLOVERLEAF SQ
Practice Address - Street 2:BLDG D3
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-2752
Practice Address - Country:US
Practice Address - Phone:276-524-1785
Practice Address - Fax:276-524-1787
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046823208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101046823Medicaid
VAC11004Medicare PIN