Provider Demographics
NPI:1609841816
Name:ELIA, MANANA B (MD)
Entity Type:Individual
Prefix:
First Name:MANANA
Middle Name:B
Last Name:ELIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANANA
Other - Middle Name:B
Other - Last Name:KVARATSKHELIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3012
Practice Address - Country:US
Practice Address - Phone:626-256-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28675207RH0003X
MO2002007883207RH0003X
CAC177706207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100428760BMedicaid
MO1609841816Medicaid
KS100428760BMedicaid
MOH56073Medicare UPIN
MOMA3347026Medicare PIN