Individual
MANOLO M. MANALO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2516 E DUPONT RD, FORT WAYNE, IN 46825-1608
(260) 471-7197
(260) 471-7408
Mailing address
6920 POINTE INVERNESS WAY STE 200, FORT WAYNE, IN 46804-7934
(260) 479-3516
(260) 479-3520
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01041487A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000091895
BLUE CROSS BLUE SHIELD
—
05
—
100326320
—
IN
01
—
P00970644
RAILROAD MEDICARE
IN
Enumeration date
11/04/2005
Last updated
10/13/2020
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