Provider Demographics
NPI:1568810745
Name:MANJUNATH, AEKTA KAUSHIK (MD)
Entity Type:Individual
Prefix:
First Name:AEKTA
Middle Name:KAUSHIK
Last Name:MANJUNATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AEKTA
Other - Middle Name:KAUSHIK
Other - Last Name:MANJUNATH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:180 HARVESTER DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-7594
Mailing Address - Country:US
Mailing Address - Phone:773-702-1150
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:MC 8016, K155
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-702-7553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-29
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.068631208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No208000000XAllopathic & Osteopathic PhysiciansPediatrics