Provider Demographics
NPI:1336168426
Name:MANJUL PATWARDHAN MD PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MANJUL PATWARDHAN MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANJUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:PATWARDHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-725-1777
Mailing Address - Street 1:898 PERSIMMON AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-1819
Mailing Address - Country:US
Mailing Address - Phone:408-219-3130
Mailing Address - Fax:
Practice Address - Street 1:10353 TORRE AVE
Practice Address - Street 2:STE A
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3217
Practice Address - Country:US
Practice Address - Phone:408-725-1777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A691820Medicare ID - Type UnspecifiedMEDICARE ID
CAH29284Medicare UPIN