Provider Demographics
NPI:1497281588
Name:MANJUNATH, SHWETHA (MD)
Entity Type:Individual
Prefix:
First Name:SHWETHA
Middle Name:
Last Name:MANJUNATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 COMMERCE DR STE 500
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8736
Mailing Address - Country:US
Mailing Address - Phone:847-698-0600
Mailing Address - Fax:847-698-0601
Practice Address - Street 1:304 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4200
Practice Address - Country:US
Practice Address - Phone:630-262-8554
Practice Address - Fax:630-208-7363
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
390200000X
IL0361589382085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036158938OtherILLINOIS STATE LICENSE