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NPI Code Detail

MEDICARE: MARILISA MANCAO MD

MEDICARE: MARILISA MANCAO 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
1207Q00000XFamily Medicine Physician98109NM
2207Q00000XFamily Medicine PhysicianG161069CA

General Provider Information

NPI Number : 1912982455
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARILISA MANCAO MD
Provider Business Mailing Address
First Line : 10700 MACARTHUR BLVD
Second Line :
City : OAKLAND
State : CA
Zip : 94605-5298
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : US HWY 491 NORTH
Second Line :
City : SHIPROCK
State : NM
Zip : 87420-0160
Country : US
Telephone Number : 505-368-6001
Fax Number : 505-368-7011
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/07/2005
Last Update Date : 02/08/2021

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