Healthcare Provider Details

I. General information

NPI: 1013466598
Provider Name (Legal Business Name): JAYA PRASAD SHANMUGAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 E FRANK PHILLIPS BLVD STE 301
BARTLESVILLE OK
74006-2439
US

IV. Provider business mailing address

2431 E 61ST ST STE 500
TULSA OK
74136-1208
US

V. Phone/Fax

Practice location:
  • Phone: 918-582-6800
  • Fax: 918-582-6060
Mailing address:
  • Phone: 918-582-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number310210
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberR-10460
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number04-43900
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: