Healthcare Provider Details

I. General information

NPI: 1902047814
Provider Name (Legal Business Name): SHASHANK JOLLY M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 HEALTH CAMPUS DR STE 200
ROCKINGHAM VA
22801-8679
US

IV. Provider business mailing address

46689 WINDMILL DR
FREMONT CA
94539-7238
US

V. Phone/Fax

Practice location:
  • Phone: 540-689-5555
  • Fax:
Mailing address:
  • Phone: 408-389-8774
  • Fax: 408-516-9377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD430577
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA126261
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number11204
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01081142A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: