Provider Demographics
NPI:1053413856
Name:MANALAC, MICHELLE MASCARINAS (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MASCARINAS
Last Name:MANALAC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4069 LAKE DR SE STE 315
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8816
Practice Address - Country:US
Practice Address - Phone:616-267-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077123207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4427087Medicaid
MIH67219Medicare UPIN
MI4427087Medicaid