Healthcare Provider Details

I. General information

NPI: 1346237013
Provider Name (Legal Business Name): DEVENDRA T SHANTHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SPRING ST
GREENWOOD SC
29646-3860
US

IV. Provider business mailing address

706 HOLLYWOOD ST.
SPARTANBURG SC
29302
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-4111
  • Fax:
Mailing address:
  • Phone: 770-330-5684
  • Fax: 864-560-6276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number19132
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: