MEDICARE: SHANTHA KESAVULU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	GO742	TX

General Provider Information

NPI Number	:	1942236567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTHA KESAVULU M.D.

Provider Business Mailing Address
First Line	:	4242 E SOUTHCROSS BLVD STE 6
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78222-3728
Country	:	US
Telephone Number	:	210-333-4638
Fax Number	:

Provider Business Practice Location Address
First Line	:	4242 E SOUTHCROSS BLVD STE 6
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78222-3728
Country	:	US
Telephone Number	:	210-333-4638
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2006
Last Update Date	:	07/12/2007

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