Healthcare Provider Details

I. General information

NPI: 1801990254
Provider Name (Legal Business Name): MANJALI SUSHIL SHASTRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1787 S M 52
OWOSSO MI
48867-9201
US

IV. Provider business mailing address

1787 S M 52
OWOSSO MI
48867-9201
US

V. Phone/Fax

Practice location:
  • Phone: 989-729-4600
  • Fax: 989-725-5760
Mailing address:
  • Phone: 989-729-4600
  • Fax: 989-725-5760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301069446
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: