Healthcare Provider Details

I. General information

NPI: 1598901431
Provider Name (Legal Business Name): SUJATA MADHUKAR SHANBHAG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2008
Last Update Date: 12/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CENTER DRIVE, BLDG 10 ROOM B1D-416, MSC-1061
BETHESDA MD
20892-1061
US

IV. Provider business mailing address

10 CENTER DRIVE, BLDG 10 ROOM B1D-416, MSC-1061
BETHESDA MD
20892-1061
US

V. Phone/Fax

Practice location:
  • Phone: 301-496-3658
  • Fax: 301-896-7521
Mailing address:
  • Phone: 301-496-3658
  • Fax: 301-896-7521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD0065619
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: