Healthcare Provider Details

I. General information

NPI: 1801995535
Provider Name (Legal Business Name): NAGARAKERE R SHANKARAIAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 S CONGRESS AVE SUITE A
PALM SPRINGS FL
33461
US

IV. Provider business mailing address

3112 S CONGRESS AVE SUITE A
PALM SPRINGS FL
33461
US

V. Phone/Fax

Practice location:
  • Phone: 561-964-0110
  • Fax: 561-964-0401
Mailing address:
  • Phone: 561-964-0110
  • Fax: 561-964-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME57808
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: