Provider Demographics
NPI:1528251618
Name:RAJU, MANJUNATH GOPAL
Entity type:Individual
Prefix:
First Name:MANJUNATH
Middle Name:GOPAL
Last Name:RAJU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1411
Mailing Address - Fax:
Practice Address - Street 1:3311 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477
Practice Address - Country:US
Practice Address - Phone:541-484-4332
Practice Address - Fax:541-302-0786
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD181855207RC0000X, 207RI0011X
MI4301090348207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease