Healthcare Provider Details

I. General information

NPI: 1568480341
Provider Name (Legal Business Name): SHANI VATURI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7264 WARREN SHARON RD
BROOKFIELD OH
44403-9665
US

IV. Provider business mailing address

PO BOX 1208
HERMITAGE PA
16148-0208
US

V. Phone/Fax

Practice location:
  • Phone: 330-448-3060
  • Fax: 330-448-2555
Mailing address:
  • Phone: 330-448-3060
  • Fax: 330-448-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD052456L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35062216
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: