Provider Demographics
NPI:1730129065
Name:MANELLA, SUSAN G (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
Last Name:MANELLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 N HIATUS ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-5206
Mailing Address - Country:US
Mailing Address - Phone:954-381-8989
Mailing Address - Fax:954-381-8950
Practice Address - Street 1:500 N HIATUS RD STE 201
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-5213
Practice Address - Country:US
Practice Address - Phone:954-381-8989
Practice Address - Fax:954-381-8950
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256367300Medicaid
FL256367300Medicaid
FL82729BMedicare PIN