MEDICARE: SHANTI K NEERUKONDA M.D.

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	207RI0011X	Interventional Cardiology Physician	K0148	TX

General Provider Information

NPI Number	:	1740219807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTI K NEERUKONDA M.D.

Provider Business Mailing Address
First Line	:	501 GOLDER AVE STE 202-A
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-4411
Country	:	US
Telephone Number	:	432-333-6200
Fax Number	:	432-333-6213

Provider Business Practice Location Address
First Line	:	501 GOLDER AVE STE 202-A
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-4411
Country	:	US
Telephone Number	:	432-333-6200
Fax Number	:	432-333-6213

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

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	06/20/2018

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