Provider Demographics
NPI:1386603462
Name:BACALLAO, MANUEL DEJESUS (MD)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:DEJESUS
Last Name:BACALLAO
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 1:8525 SW 92 STREET
Mailing Address - Street 2:SUITE B 4
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7374
Mailing Address - Country:US
Mailing Address - Phone:305-279-7446
Mailing Address - Fax:305-598-8753
Practice Address - Street 1:8525 SW 92 STREET
Practice Address - Street 2:SUITE B 4
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7374
Practice Address - Country:US
Practice Address - Phone:305-279-7446
Practice Address - Fax:305-598-8753
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL96980Medicare ID - Type Unspecified
D77138Medicare UPIN