Provider Demographics
NPI:1316997059
Name:MANALO, GEORGE QUESADA (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:QUESADA
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 1:2124 W DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-1431
Mailing Address - Country:US
Mailing Address - Phone:215-684-0801
Mailing Address - Fax:215-235-0317
Practice Address - Street 1:2124 W DIAMOND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-1431
Practice Address - Country:US
Practice Address - Phone:215-684-0801
Practice Address - Fax:215-235-0317
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2016-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039094L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009095240001Medicaid
PA184787Medicare ID - Type Unspecified
PA0009095240001Medicaid