Provider Demographics
NPI:1225024896
Name:NATHAN, MANJUNATH (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJUNATH
Middle Name:
Last Name:NATHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MANJUANTH
Other - Middle Name:
Other - Last Name:PARATHASARATHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2095 W 24TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6242
Mailing Address - Country:US
Mailing Address - Phone:928-328-8393
Mailing Address - Fax:928-344-4166
Practice Address - Street 1:2095 W 24TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6242
Practice Address - Country:US
Practice Address - Phone:928-328-8393
Practice Address - Fax:928-344-4166
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
167365Medicare UPIN