Provider Demographics
NPI:1073527594
Name:SHASTRI, SUBRAMANYA R (MD)
Entity Type:Individual
Prefix:DR
First Name:SUBRAMANYA
Middle Name:R
Last Name:SHASTRI
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 1:17 LIMESTONE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8600
Mailing Address - Country:US
Mailing Address - Phone:716-565-3390
Mailing Address - Fax:716-565-3392
Practice Address - Street 1:17 LIMESTONE DR STE 1
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8600
Practice Address - Country:US
Practice Address - Phone:716-565-3390
Practice Address - Fax:716-565-3392
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135351-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist