Provider Demographics
NPI:1144259391
Name:MANANSALA, ANGELA GLORIA (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:GLORIA
Last Name:MANANSALA
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 1:5861 N ORACLE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3813
Mailing Address - Country:US
Mailing Address - Phone:520-293-6686
Mailing Address - Fax:520-887-1736
Practice Address - Street 1:5861 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3813
Practice Address - Country:US
Practice Address - Phone:520-293-6686
Practice Address - Fax:520-887-1736
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063450207PE0004X
AZ42024208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAM063450OtherBC/BS OF MICHIGAN
AZ436721OtherAHCCCS
MI104322316Medicaid
AZ436721Medicaid
MIAM063450OtherBC/BS OF MICHIGAN
MIM48310070Medicare ID - Type Unspecified