Provider Demographics
NPI:1609852268
Name:MANEY, THOMAS WADE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WADE
Last Name:MANEY
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 1:2261 DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3831
Mailing Address - Country:US
Mailing Address - Phone:916-783-1044
Mailing Address - Fax:916-773-3405
Practice Address - Street 1:2261 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3831
Practice Address - Country:US
Practice Address - Phone:916-783-1044
Practice Address - Fax:916-773-3405
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55131208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG48385Medicare UPIN
CA00A551311Medicare PIN