Healthcare Provider Details

I. General information

NPI: 1871484345
Provider Name (Legal Business Name): KEERTHANA MANJUNATH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W POLK ST STE 5210
CHICAGO IL
60612-3723
US

IV. Provider business mailing address

513 S DAMEN AVE APT 1802
CHICAGO IL
60612-5596
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-7311
  • Fax:
Mailing address:
  • Phone: 312-221-6462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.085279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: