MEDICARE: MR. MANUEL DEJESUS BACALLAO MD

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	207Q00000X	Family Medicine Physician	ME38837	FL

General Provider Information

NPI Number	:	1386603462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MANUEL DEJESUS BACALLAO MD

Provider Business Mailing Address
First Line	:	8525 SW 92 STREET
Second Line	:	SUITE B 4
City	:	MIAMI
State	:	FL
Zip	:	33156-7374
Country	:	US
Telephone Number	:	305-279-7446
Fax Number	:	305-598-8753

Provider Business Practice Location Address
First Line	:	8525 SW 92 STREET
Second Line	:	SUITE B 4
City	:	MIAMI
State	:	FL
Zip	:	33156-7374
Country	:	US
Telephone Number	:	305-279-7446
Fax Number	:	305-598-8753

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

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	08/03/2010

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