Provider Demographics
NPI:1679672422
Name:BACULI, MANUEL NOBLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:NOBLE
Last Name:BACULI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2040 PACIFIC COAST HWY STE S
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-2660
Mailing Address - Country:US
Mailing Address - Phone:424-347-8008
Mailing Address - Fax:844-481-9664
Practice Address - Street 1:2040 PACIFIC COAST HWY STE S
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-2660
Practice Address - Country:US
Practice Address - Phone:424-347-8008
Practice Address - Fax:844-481-9664
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25005207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24244Medicare UPIN