Basic Information
| Provider Information | |||||||||
| NPI: | 1982197521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALDONADO-VITAL | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MALDONADO | ||||||||
| OtherFirstName: | MANUEL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 940 STANTON L YOUNG BLVD | ||||||||
| Address2: | BMSB 451 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 73104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052712451 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 940 STANTON L YOUNG BLVD | ||||||||
| Address2: | BMSB 451 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 73104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052712451 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2018 | ||||||||
| LastUpdateDate: | 06/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.