Healthcare Provider Details

I. General information

NPI: 1396768958
Provider Name (Legal Business Name): SHANTHA KUMAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 S GOLD DR
APACHE JUNCTION AZ
85120-5035
US

IV. Provider business mailing address

99 S GOLD DR
APACHE JUNCTION AZ
85120-5030
US

V. Phone/Fax

Practice location:
  • Phone: 480-962-0101
  • Fax: 480-962-0202
Mailing address:
  • Phone: 480-962-0101
  • Fax: 480-962-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number23951
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number23951
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: