Provider Demographics
NPI:1013397652
Name:MANJULA MUPPU MD PC
Entity Type:Organization
Organization Name:MANJULA MUPPU MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANJULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUPPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-998-4151
Mailing Address - Street 1:5280 MONTIANO CT
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2917
Mailing Address - Country:US
Mailing Address - Phone:925-998-4151
Mailing Address - Fax:
Practice Address - Street 1:5280 MONTIANO CT
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-2917
Practice Address - Country:US
Practice Address - Phone:925-998-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115266207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA115266OtherMEDICAL LICENSE
CAFM2564676OtherDEA