Provider Demographics
NPI:1063443885
Name:MANAM, BOB A (MD)
Entity Type:Individual
Prefix:DR
First Name:BOB
Middle Name:A
Last Name:MANAM
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 1:2020 OGDEN AVE
Mailing Address - Street 2:STE 140
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-5894
Mailing Address - Country:US
Mailing Address - Phone:630-851-1144
Mailing Address - Fax:
Practice Address - Street 1:2020 OGDEN AVE
Practice Address - Street 2:STE 140
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-5894
Practice Address - Country:US
Practice Address - Phone:630-851-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077740207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360377740Medicaid
IL23697Medicare UPIN
380970Medicare PIN