Provider Demographics
NPI:1336408905
Name:MANABAT, MIA L (DO)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:L
Last Name:MANABAT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 S 90TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2455
Mailing Address - Country:US
Mailing Address - Phone:414-328-8750
Mailing Address - Fax:586-582-6631
Practice Address - Street 1:2424 S 90TH ST STE 300
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227
Practice Address - Country:US
Practice Address - Phone:414-328-8750
Practice Address - Fax:586-582-6631
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69852-21207RG0100X
WI69852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100080507Medicaid