Provider Demographics
NPI:1316105547
Name:MAHADEVAPPA, MANJUNATH C (MD)
Entity type:Individual
Prefix:DR
First Name:MANJUNATH
Middle Name:C
Last Name:MAHADEVAPPA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 MARYLAND WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5064
Mailing Address - Country:US
Mailing Address - Phone:615-371-5765
Mailing Address - Fax:888-241-1404
Practice Address - Street 1:601 N ELM ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4331
Practice Address - Country:US
Practice Address - Phone:336-878-6419
Practice Address - Fax:336-878-6436
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.090795207R00000X
NC2009-00409207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC153RHOtherBLUE CROSS/BLUE SHIELD OF NORTH CAROLINA
NC5912568Medicaid
NC5912568Medicaid