Provider Demographics
NPI:1437576824
Name:MANUBOLU, VENKAT SANJAY REDDY (MD)
Entity Type:Individual
Prefix:
First Name:VENKAT SANJAY REDDY
Middle Name:
Last Name:MANUBOLU
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 1:1313 E HERNDON AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3306
Mailing Address - Country:US
Mailing Address - Phone:559-450-5375
Mailing Address - Fax:
Practice Address - Street 1:1313 E HERNDON AVE STE 105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-450-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA153613207R00000X
MA273190207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine