Provider Demographics
NPI:1750526471
Name:MANJUNATH, SHWETHA (MD)
Entity type:Individual
Prefix:
First Name:SHWETHA
Middle Name:
Last Name:MANJUNATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-0928
Mailing Address - Country:US
Mailing Address - Phone:224-717-6206
Mailing Address - Fax:
Practice Address - Street 1:2222 WEBER RD
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-0928
Practice Address - Country:US
Practice Address - Phone:224-717-6206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125050788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine