Basic Information
| Provider Information | |||||||||
| NPI: | 1366472441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANJUNATH | ||||||||
| FirstName: | HEERAIMANGALORE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581023641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342371 | ||||||||
| FaxNumber: | 7012343813 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581023641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342371 | ||||||||
| FaxNumber: | 7012343813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0001X | 9450 | ND | Y | 207RC0000X | 9450 | ND | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2259002 | 01 | ND | AMERICA'S PPO/ARAZ # | OTHER | HP48027 | 01 | ND | HEALTHPARTNERS # | OTHER | 137120 | 01 | ND | UCARE # | OTHER | 27208 | 01 | ND | ND BCBS | OTHER | 917D5MA | 01 | ND | MNBS # | OTHER | 12427 | 05 | ND | MEDICAID | 2501717 | 01 | ND | MEDICA # | OTHER | 2502164 | 01 | MEDICA | OTHER | 806926300 | 05 | MN | MEDICAID | DA9011042786 | 01 | ND | PREFERRED ONE # | OTHER | 25027 | 01 | ND | NDBS # | OTHER | 37999 | 01 | ND | LHS # | OTHER | 600G7MA | 01 | MN | MN BCBS | OTHER | HP48027 | 01 | HEALTPARTNERS | OTHER | 1042786 | 01 | PREFERREDONE | OTHER | 806926300 | 05 | ND | MEDICAID | 2501505 | 01 | ND | MEDICA # | OTHER |