MEDICARE: TINA YUN MANTANONA 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	A129087	CA
2	207Q00000X	Family Medicine Physician	036144032	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922362623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA YUN MANTANONA MD

Provider Business Mailing Address
First Line	:	1475 E BELVIDERE RD UNIT 385
Second Line	:
City	:	GRAYSLAKE
State	:	IL
Zip	:	60030-2026
Country	:	US
Telephone Number	:	847-537-7157
Fax Number	:

Provider Business Practice Location Address
First Line	:	1475 E BELVIDERE RD UNIT 385
Second Line	:
City	:	GRAYSLAKE
State	:	IL
Zip	:	60030-2026
Country	:	US
Telephone Number	:	847-537-7157
Fax Number	:

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

Provider Enumeration Date	:	06/27/2012
Last Update Date	:	07/21/2022

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Directions to “ TINA YUN MANTANONA MD” Practice Location

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