Provider Demographics
NPI:1043874498
Name:SHANMUGIAVELAYUTHAM, SWABNA K (MD)
Entity Type:Individual
Prefix:
First Name:SWABNA
Middle Name:K
Last Name:SHANMUGIAVELAYUTHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-3037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE # 1
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:630-335-1652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL125077109208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program