Provider Demographics
NPI:1154825305
Name:SHASTRY, SONIA (DO)
Entity Type:Individual
Prefix:
First Name:SONIA
Middle Name:
Last Name:SHASTRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 AAA BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-3624
Mailing Address - Country:US
Mailing Address - Phone:302-918-6400
Mailing Address - Fax:
Practice Address - Street 1:875 AAA BLVD STE C
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-3624
Practice Address - Country:US
Practice Address - Phone:302-918-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0023911208000000X
PAOT018461390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program