Provider Demographics
NPI:1366472441
Name:MANJUNATH, HEERAIMANGALORE S (MD)
Entity Type:Individual
Prefix:
First Name:HEERAIMANGALORE
Middle Name:S
Last Name:MANJUNATH
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 1:801 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-2371
Mailing Address - Fax:701-234-3813
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2371
Practice Address - Fax:701-234-3813
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9450207RA0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2259002OtherAMERICA'S PPO/ARAZ #
NDHP48027OtherHEALTHPARTNERS #
ND137120OtherUCARE #
ND27208OtherND BCBS
ND917D5MAOtherMNBS #
ND12427Medicaid
ND2501717OtherMEDICA #
2502164OtherMEDICA
MN806926300Medicaid
NDDA9011042786OtherPREFERRED ONE #
ND25027OtherNDBS #
ND37999OtherLHS #
MN600G7MAOtherMN BCBS
HP48027OtherHEALTPARTNERS
1042786OtherPREFERREDONE
ND806926300Medicaid
ND2501505OtherMEDICA #
ND25027OtherNDBS #
G56577Medicare UPIN
ND37999OtherLHS #
MN806926300Medicaid