Healthcare Provider Details

I. General information

NPI: 1346270063
Provider Name (Legal Business Name): THEODORE ANDREW MANOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8424 E SHEA BLVD STE. 101
SCOTTSDALE AZ
85260-6662
US

IV. Provider business mailing address

30099 N 129TH DR
PEORIA AZ
85383-5267
US

V. Phone/Fax

Practice location:
  • Phone: 480-256-1520
  • Fax: 480-478-6628
Mailing address:
  • Phone: 928-501-6666
  • Fax: 928-501-6566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number37050
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number37050
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number37050
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: