Healthcare Provider Details

I. General information

NPI: 1164457560
Provider Name (Legal Business Name): HAROHALLI R SHASHIDHAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MAMMOTH RD SUITE 1
MANCHESTER NH
03109-4133
US

IV. Provider business mailing address

275 MAMMOTH RD
MANCHESTER NH
03109-4133
US

V. Phone/Fax

Practice location:
  • Phone: 603-663-3222
  • Fax:
Mailing address:
  • Phone: 603-663-3222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number34403
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number15360
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: