Healthcare Provider Details

I. General information

NPI: 1659935104
Provider Name (Legal Business Name): SHANTHI CHODAGIRI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11529 TREEVIEW CT
MOORPARK CA
93021-3734
US

IV. Provider business mailing address

11529 TREEVIEW CT
MOORPARK CA
93021-3734
US

V. Phone/Fax

Practice location:
  • Phone: 585-615-5351
  • Fax:
Mailing address:
  • Phone: 585-615-5351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA57319
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: