Provider Demographics
NPI:1912982455
Name:MANCAO, MARILISA (MD)
Entity Type:Individual
Prefix:
First Name:MARILISA
Middle Name:
Last Name:MANCAO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:LISA
Other - Last Name:MANCAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10700 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-5298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-0160
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:505-368-7011
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98109207Q00000X
CAG161069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS7169Medicaid
AZ429218Medicaid
CO89877012Medicaid
G49018Medicare UPIN
8HZD03Medicare PIN
320059Medicare Oscar/Certification