Provider Demographics
NPI:1588784896
Name:MANALOTO, THERESA (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:MANALOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8001 MADISON AVE
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-7901
Practice Address - Country:US
Practice Address - Phone:916-536-2420
Practice Address - Fax:916-962-0335
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93110OtherSTATE LICENSE
CA00A931100Medicaid
CAI46267Medicare UPIN
CA00A931100Medicaid