Provider Demographics
NPI:1942483136
Name:MANQUBAT, OPHELIA V (MD)
Entity Type:Individual
Prefix:
First Name:OPHELIA
Middle Name:V
Last Name:MANQUBAT
Suffix:
Gender:F
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 750370
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45475-0370
Mailing Address - Country:US
Mailing Address - Phone:937-266-8267
Mailing Address - Fax:937-436-3717
Practice Address - Street 1:2739 MIAMI VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342
Practice Address - Country:US
Practice Address - Phone:937-266-8267
Practice Address - Fax:937-436-3717
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100223208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0272726Medicaid