1487018586 NPI number — SHANTI MANGALASSERIL SHIVAJI MD

Table of content: SHANTI MANGALASSERIL SHIVAJI MD (NPI 1487018586)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487018586 NPI number — SHANTI MANGALASSERIL SHIVAJI MD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
SHIVAJI

Provider First Name:
SHANTI

Provider Middle Name:
MANGALASSERIL

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
MD

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487018586

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
07/06/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1730 BALDWIN DR

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
MC LEAN

Provider Business Mailing Address State Name:
VA

Provider Business Mailing Address Postal Code:
22101-5048

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
703-442-0486

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 N ELAM AVE STE 101

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
GREENSBORO

Provider Business Practice Location Address State Name:
NC

Provider Business Practice Location Address Postal Code:
27403-1135

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
336-854-8800

Provider Business Practice Location Address Fax Number:
336-834-0595

Provider Enumeration Date:
04/05/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 207V00000X , with the licence number: 202002975 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .