Healthcare Provider Details

I. General information

NPI: 1790971026
Provider Name (Legal Business Name): MARISA AGUILA-MANALO, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE SUITE 312
CHICAGO IL
60631-3745
US

IV. Provider business mailing address

7447 W TALCOTT AVE SUITE 312
CHICAGO IL
60631-3745
US

V. Phone/Fax

Practice location:
  • Phone: 773-467-9925
  • Fax: 773-467-9938
Mailing address:
  • Phone: 773-467-9925
  • Fax: 773-467-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. MARISA AGUILA-MANALO
Title or Position: OWNER
Credential: M.D.
Phone: 773-467-9925