Healthcare Provider Details

I. General information

NPI: 1366722191
Provider Name (Legal Business Name): MANJU BENGALURU JAYANNA MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 08/10/2025
Certification Date: 08/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 OLD LANCASTER RD STE 400
BRYN MAWR PA
19010-3236
US

IV. Provider business mailing address

825 OLD LANCASTER RD STE 320
BRYN MAWR PA
19010-3235
US

V. Phone/Fax

Practice location:
  • Phone: 610-525-1202
  • Fax: 610-527-0643
Mailing address:
  • Phone: 610-527-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6616
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD473091
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD-42601
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD473091
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number42601
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: