Healthcare Provider Details

I. General information

NPI: 1700883980
Provider Name (Legal Business Name): SHANTHARAMA KARANTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 SUDLEY RD
MANASSAS VA
20110-4418
US

IV. Provider business mailing address

9241 RAINBOW FALLS DR
BRISTOW VA
20136-2137
US

V. Phone/Fax

Practice location:
  • Phone: 703-369-8134
  • Fax: 703-369-8234
Mailing address:
  • Phone: 703-361-4199
  • Fax: 703-369-8234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101042860
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: