Basic Information
| Provider Information | |||||||||
| NPI: | 1629227616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIRIGERE MANJUNATH | ||||||||
| FirstName: | PRASHANTH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3269 N STOCKTON HILL RD | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864093619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287572101 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3801 SANTA ROSA DR | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864012311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286818570 | ||||||||
| FaxNumber: | 9286818569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | M11963 | ID | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 64661 | AZ | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.