Provider Demographics
NPI:1942493812
Name:ALCANTARA, FREDERICK MANALO (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:MANALO
Last Name:ALCANTARA
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 1:252 HANALEI DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4263
Mailing Address - Country:US
Mailing Address - Phone:304-594-0916
Mailing Address - Fax:
Practice Address - Street 1:2048 VIP WAY
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-366-6200
Practice Address - Fax:304-366-4927
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432566174400000X
WV23746207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAAL1983636OtherBLUE SHIELD
PAP00434792OtherMEDICARE TRAVELERS
PA1020032650001Medicaid
PA1020032650001Medicaid