=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902047814
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHASHANK JOLLY M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2009
-----------------------------------------------------
Last Update Date | 07/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2006 HEALTH CAMPUS DR STE 200
-----------------------------------------------------
City | ROCKINGHAM
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22801-8679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-689-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46689 WINDMILL DR
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94539-7238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-389-8774
-----------------------------------------------------
Fax | 408-516-9377
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | MD430577
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | A126261
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 11204
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 01081142A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------