Provider Demographics
NPI:1679859359
Name:MANOLITO B. FIDEL, M.D., INC
Entity type:Organization
Organization Name:MANOLITO B. FIDEL, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MANOLITO
Authorized Official - Middle Name:B
Authorized Official - Last Name:FIDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:424-400-7748
Mailing Address - Street 1:28919 COVECREST DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-4703
Mailing Address - Country:US
Mailing Address - Phone:424-400-7748
Mailing Address - Fax:424-400-7749
Practice Address - Street 1:23700 CAMINO DEL SOL
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5017
Practice Address - Country:US
Practice Address - Phone:310-530-1151
Practice Address - Fax:310-626-9390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA819092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A819090Medicaid
H82216Medicare UPIN
A81909Medicare PIN