Provider Demographics
NPI:1619067428
Name:BENAKANAHALLI, MANJUNATH B (MD)
Entity type:Individual
Prefix:
First Name:MANJUNATH
Middle Name:B
Last Name:BENAKANAHALLI
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 1:603 W LUMSDEN RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5911
Mailing Address - Country:US
Mailing Address - Phone:813-435-3912
Mailing Address - Fax:813-655-3913
Practice Address - Street 1:603 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5911
Practice Address - Country:US
Practice Address - Phone:813-435-3912
Practice Address - Fax:813-655-3913
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH22471Medicare UPIN
FLAG914XMedicare PIN