Healthcare Provider Details

I. General information

NPI: 1962024778
Provider Name (Legal Business Name): SHANU PREETHA MOORTHY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205A BELLE MEADE PT
FLOWOOD MS
39232-3311
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-5678
  • Fax: 601-200-5678
Mailing address:
  • Phone: 601-200-5678
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33023
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33023
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number84112
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number84112
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: