Provider Demographics
NPI:1366722191
Name:BENGALURU JAYANNA, MANJU (MBBS)
Entity type:Individual
Prefix:
First Name:MANJU
Middle Name:
Last Name:BENGALURU JAYANNA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 OLD LANCASTER RD STE 400
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3236
Mailing Address - Country:US
Mailing Address - Phone:610-525-1202
Mailing Address - Fax:
Practice Address - Street 1:825 OLD LANCASTER RD STE 400
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3236
Practice Address - Country:US
Practice Address - Phone:610-525-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-42601208M00000X
IA42601207R00000X
PAMD473091207RI0011X, 207RC0000X
NE6616207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease