Provider Demographics
NPI:1437319308
Name:BANNUR, MANJUNATH RACHOTEPPA (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJUNATH
Middle Name:RACHOTEPPA
Last Name:BANNUR
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 1:716 HANEY ST
Mailing Address - Street 2:
Mailing Address - City:SPEARMAN
Mailing Address - State:TX
Mailing Address - Zip Code:79081-3550
Mailing Address - Country:US
Mailing Address - Phone:989-948-7719
Mailing Address - Fax:
Practice Address - Street 1:707 ROLAND ST
Practice Address - Street 2:
Practice Address - City:SPEARMAN
Practice Address - State:TX
Practice Address - Zip Code:79081-3441
Practice Address - Country:US
Practice Address - Phone:806-659-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18885207P00000X
TXQ2240207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine