Provider Demographics
NPI:1124176987
Name:MANOGURA, ANITA CHANDRATHIL (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:CHANDRATHIL
Last Name:MANOGURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:ACHAMMA
Other - Last Name:CHANDRATHIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 743
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60121
Mailing Address - Country:US
Mailing Address - Phone:224-773-8975
Mailing Address - Fax:
Practice Address - Street 1:1425 N RANDALL RD
Practice Address - Street 2:SHERMAN HOSP STE 1-2150
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2300
Practice Address - Country:US
Practice Address - Phone:224-773-8975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-108204207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124176987OtherINDIVIDUAL NPI