Provider Demographics
NPI:1174611750
Name:ZEVALLOS, MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
Last Name:ZEVALLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18000 STUDEBAKER RD STE 800
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2671
Mailing Address - Country:US
Mailing Address - Phone:562-735-3226
Mailing Address - Fax:
Practice Address - Street 1:3628 E IMPERIAL HWY STE 401
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2646
Practice Address - Country:US
Practice Address - Phone:310-667-4000
Practice Address - Fax:310-667-4010
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35871174400000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA84824Medicare PIN