MEDICARE: MABBU GAJAPATHY SHIVAPRASAD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35-072257	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083795850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MABBU GAJAPATHY SHIVAPRASAD MD

Provider Business Mailing Address
First Line	:	2210 TIMBER TRAIL
Second Line	:
City	:	BELLEFONTAINE
State	:	OH
Zip	:	43311
Country	:	US
Telephone Number	:	937-593-3151
Fax Number	:	937-593-5438

Provider Business Practice Location Address
First Line	:	LOGAN FAMILY MEDICAL CENTER LLC
Second Line	:	2210 TIMBER TRAIL
City	:	BELLEFONTAINE
State	:	OH
Zip	:	43311
Country	:	US
Telephone Number	:	937-593-3151
Fax Number	:	937-593-5438

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	07/08/2007

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