Provider Demographics
NPI:1770683450
Name:PRABHU, MANJESHWAR B (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJESHWAR
Middle Name:B
Last Name:PRABHU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1770 E LAKE SHORE DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3832
Mailing Address - Country:US
Mailing Address - Phone:217-464-1350
Mailing Address - Fax:217-464-1359
Practice Address - Street 1:1730 E LAKE SHORE DR STE 301
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3809
Practice Address - Country:US
Practice Address - Phone:217-329-1000
Practice Address - Fax:217-329-1055
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036083999207R00000X, 207RS0012X
IL036-083999207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083999Medicaid
F36793Medicare UPIN