Provider Demographics
NPI:1750471546
Name:MANJOORAN, EARNEST GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:EARNEST
Middle Name:GEORGE
Last Name:MANJOORAN
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 1:588 N SUNRISE AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2842
Mailing Address - Country:US
Mailing Address - Phone:916-781-9885
Mailing Address - Fax:916-781-7923
Practice Address - Street 1:588 N SUNRISE AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2842
Practice Address - Country:US
Practice Address - Phone:916-781-9885
Practice Address - Fax:916-781-7923
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33822207R00000X
CAC133271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ923517Medicaid
CAC133271OtherMEDICAL LICENSE
AZ923517Medicaid