Healthcare Provider Details

I. General information

NPI: 1043267685
Provider Name (Legal Business Name): KALATHIL K. SHASHIDHARAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD
BALTIMORE MD
21239-2905
US

IV. Provider business mailing address

307 S EVERGREEN AVE
WOODBURY NJ
08096-2739
US

V. Phone/Fax

Practice location:
  • Phone: 410-532-4040
  • Fax: 410-532-4962
Mailing address:
  • Phone: 856-686-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberD18230
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: