Healthcare Provider Details

I. General information

NPI: 1386146769
Provider Name (Legal Business Name): SANTOSH SHANMUGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 VAN AALST BLVD
FORT MOORE GA
31905-2102
US

IV. Provider business mailing address

6600 VAN AALST BLVD
FORT BENNING GA
31905-2102
US

V. Phone/Fax

Practice location:
  • Phone: 762-408-3566
  • Fax:
Mailing address:
  • Phone: 762-408-3657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0101269085
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number103003
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: