Healthcare Provider Details

I. General information

NPI: 1497281588
Provider Name (Legal Business Name): SHWETHA MANJUNATH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 RANDALL RD
GENEVA IL
60134-4200
US

IV. Provider business mailing address

700 COMMERCE DR STE 500
OAK BROOK IL
60523-8736
US

V. Phone/Fax

Practice location:
  • Phone: 630-262-8554
  • Fax: 630-208-7363
Mailing address:
  • Phone: 847-698-0600
  • Fax: 847-698-0601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036158938
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: