Provider Demographics
NPI:1053314450
Name:SHANMUGHAM, SAMPATHKUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SAMPATHKUMAR
Middle Name:
Last Name:SHANMUGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 STIRLING CENTER PL
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5714
Mailing Address - Country:US
Mailing Address - Phone:407-333-1718
Mailing Address - Fax:407-333-1633
Practice Address - Street 1:755 STIRLING CENTER PL
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5714
Practice Address - Country:US
Practice Address - Phone:407-333-1718
Practice Address - Fax:407-333-1633
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50877174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371422500Medicaid
FL05949Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE ID
FL371422500Medicaid