Provider Demographics
NPI:1164472346
Name:SHAKKOTTAI, PADMANABHA S (MD)
Entity Type:Individual
Prefix:DR
First Name:PADMANABHA
Middle Name:S
Last Name:SHAKKOTTAI
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 1:3650 SOUTH ST
Mailing Address - Street 2:SUITE 308
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1502
Mailing Address - Country:US
Mailing Address - Phone:562-633-2275
Mailing Address - Fax:562-633-0017
Practice Address - Street 1:3650 SOUTH ST
Practice Address - Street 2:SUITE 308
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1502
Practice Address - Country:US
Practice Address - Phone:562-633-2204
Practice Address - Fax:562-633-2579
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.087634207RC0200X, 207RP1001X
CAA74331207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2666502Medicaid
IN200822020Medicaid
CA1164472346Medicaid
KY64118847Medicaid
CA1164472346Medicaid
OHSH4182371Medicare ID - Type Unspecified
IN200822020Medicaid