MEDICARE: MALERY SHASHIDHARA 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	207RG0100X	Gastroenterology Physician	ME0041924	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	79772	OTHER	FL	BLUE CROSS BLUE SHIELD
2	656482	OTHER		AETNA HMO
3	2905130	OTHER		UNITED HEALTH CARE
4	4259049	OTHER		AETNA PPO

General Provider Information

NPI Number	:	1649263872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALERY SHASHIDHARA MD

Provider Business Mailing Address
First Line	:	250 2ND ST E
Second Line	:	STE 3E
City	:	BRADENTON
State	:	FL
Zip	:	34208-1029
Country	:	US
Telephone Number	:	941-748-2417
Fax Number	:	941-748-3694

Provider Business Practice Location Address
First Line	:	250 2ND ST E
Second Line	:	STE 3E
City	:	BRADENTON
State	:	FL
Zip	:	34208-1029
Country	:	US
Telephone Number	:	941-748-2417
Fax Number	:	941-748-3694

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	07/08/2007

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Directions to “ MALERY SHASHIDHARA MD” Practice Location

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