Premalata Manickam, M.D.

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

C52156 Issued in CA

Practice address

9985 Sierra Ave
Kaiser Permanente, Mob 2B
Fontana, CA 92335-6720

Phone

(909) 427-5993

Fax

(909) 427-4287

NPI assigned

Jul 7, 2006

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Riverside, CA
  • NPI 1316979834

  Multi-Specialty

  Medicare reassignment NPD
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Baldwin Park, CA
  • NPI 1770515280

  Multi-Specialty

  Medicare reassignment NPD
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Santa Clarita, CA
  • NPI 1316409410
  NPD
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Fontana, CA
  • NPI 1689606196
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152230400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1634083200000",
    "number": "1154353654",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9985 SIERRA AVE",
            "address_2": "KAISER PERMANENTE ,PEDIATRIC CLINIC MOB 2B",
            "city": "FONTANA",
            "state": "CA",
            "postal_code": "923356720",
            "telephone_number": "909-427-5993",
            "fax_number": "909-427-4287"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9985 SIERRA AVE",
            "address_2": "KAISER PERMANENTE, MOB 2B",
            "city": "FONTANA",
            "state": "CA",
            "postal_code": "923356720",
            "telephone_number": "909-427-5993",
            "fax_number": "909-427-4287"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MANICKAM",
        "first_name": "PREMALATA",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-07-07",
        "last_updated": "2021-10-13",
        "certification_date": "2021-10-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": "CA",
            "license": "C52156",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3386785",
            "state": "MI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Southern California Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "9961 Sierra Ave",
            "city": "Fontana",
            "state": "CA",
            "country_code": "US",
            "postal_code": "923356720",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Sherine Madilane Manalo-Brosas, R.P.T.
• Manavi Dental Corporation
• Natasha Allicia Mandolang, PT, DPT
• Rainier Santos Mangali, MPT
• Amreen Maniar, DO
• Vasile Maniu
• Catalina Martinez Mann, ADC
• Julie P. Mann, MD
• Lara Dia Mansour, DO
• Nancy Manueli

• Pediatrics Physician in Fontana, CA
• Providers in Fontana, CA by specialty
• Pediatrics Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.