Provider Demographics
NPI:1083678502
Name:SHANMUGAM, NIRMALA (MD)
Entity Type:Individual
Prefix:
First Name:NIRMALA
Middle Name:
Last Name:SHANMUGAM
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:PO BOX 740177
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33474-0177
Mailing Address - Country:US
Mailing Address - Phone:561-740-2900
Mailing Address - Fax:561-434-4618
Practice Address - Street 1:6944 LAKE WORTH RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2948
Practice Address - Country:US
Practice Address - Phone:561-434-0060
Practice Address - Fax:561-434-4618
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76143207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264080500Medicaid
FL264080500Medicaid
FL13201XMedicare ID - Type Unspecified