Provider Demographics
NPI:1770634362
Name:MANJUNATH, MADHURE (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHURE
Middle Name:
Last Name:MANJUNATH
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 1:11627 E. TELEGRAPH RD.,
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670
Mailing Address - Country:US
Mailing Address - Phone:562-949-3888
Mailing Address - Fax:562-949-4858
Practice Address - Street 1:11627 E. TELEGRAPH RD.,
Practice Address - Street 2:SUITE 140
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670
Practice Address - Country:US
Practice Address - Phone:562-949-3888
Practice Address - Fax:562-949-4858
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A297580Medicaid
CAA84000Medicare UPIN
CA00A297580Medicaid