Healthcare Provider Details

I. General information

NPI: 1255934014
Provider Name (Legal Business Name): MANOGJNA RUTH PRASAD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 N BEAVER ST STE 203
FLAGSTAFF AZ
86001-3120
US

IV. Provider business mailing address

4150 V ST
SACRAMENTO CA
95817-1460
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2200
  • Fax:
Mailing address:
  • Phone: 916-734-3730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number75397
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA189776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: