MEDICARE: DR. KATHERINE ANN MANALO O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	13124T	CA
2	152W00000X	Optometrist	7481T	TX

General Provider Information

NPI Number	:	1407923055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHERINE ANN MANALO O.D.

Provider Business Mailing Address
First Line	:	2442 DAWN WAY
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-1674
Country	:	US
Telephone Number	:	415-378-0387
Fax Number	:

Provider Business Practice Location Address
First Line	:	951 EL CAMINO REAL
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-3203
Country	:	US
Telephone Number	:	650-244-9744
Fax Number	:	888-663-9146

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	10/10/2016

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