MEDICARE: SHAKTHISHREE KANDASWAMY

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	207R00000X	Internal Medicine Physician	125066454	IL
2	208M00000X	Hospitalist Physician	A157620	CA
3	207RI0200X	Infectious Disease Physician	69856	AZ

General Provider Information

NPI Number	:	1427431147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAKTHISHREE KANDASWAMY

Provider Business Mailing Address
First Line	:	5601 W EUGIE AVE STE 204
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-1258
Country	:	US
Telephone Number	:	623-250-1419
Fax Number	:

Provider Business Practice Location Address
First Line	:	5601 W EUGIE AVE STE 204
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-1258
Country	:	US
Telephone Number	:	623-250-1419
Fax Number	:

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

Provider Enumeration Date	:	06/30/2015
Last Update Date	:	11/17/2023

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Directions to “ SHAKTHISHREE KANDASWAMY ” Practice Location

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