Provider Demographics
NPI:1114318870
Name:NARLA, SHANTHI
Entity Type:Individual
Prefix:
First Name:SHANTHI
Middle Name:
Last Name:NARLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVENUE
Mailing Address - Street 2:DERMATOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5320
Mailing Address - Fax:414-805-5323
Practice Address - Street 1:9200 W WISCONSIN AVENUE
Practice Address - Street 2:DERMATOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5320
Practice Address - Fax:414-805-5323
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI82571207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1114318870Medicaid