Provider Demographics
NPI:1811980741
Name:MANALO, ROLANDO (MD)
Entity type:Individual
Prefix:
First Name:ROLANDO
Middle Name:
Last Name:MANALO
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:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-0668
Mailing Address - Country:US
Mailing Address - Phone:912-748-4527
Mailing Address - Fax:912-748-9016
Practice Address - Street 1:406 GRAY ST
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2604
Practice Address - Country:US
Practice Address - Phone:912-748-4527
Practice Address - Fax:912-748-9016
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042347208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH08745Medicare UPIN