Provider Demographics
NPI:1720047129
Name:MANNUEL, HEATHER D (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:D
Last Name:MANNUEL
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 62602
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2602
Mailing Address - Country:US
Mailing Address - Phone:410-328-2567
Mailing Address - Fax:410-328-6896
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-2567
Practice Address - Fax:410-328-0248
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0057936207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS053-0058OtherBC/BS REGIONAL
MD409075600Medicaid
MD647223-01OtherBC/BS
MDP00647194Medicare PIN
MDS053-0058OtherBC/BS REGIONAL
MDQ480Medicare PIN