Provider Demographics
NPI:1215581517
Name:PADMANABHAN, SHANMUGHA VIGNESHWAR (MBBS)
Entity Type:Individual
Prefix:DR
First Name:SHANMUGHA VIGNESHWAR
Middle Name:
Last Name:PADMANABHAN
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 RIDGE AVE
Mailing Address - Street 2:MEDICAL EDUCATION
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3432
Mailing Address - Country:US
Mailing Address - Phone:847-316-4000
Mailing Address - Fax:
Practice Address - Street 1:355 RIDGE AVE
Practice Address - Street 2:MEDICAL EDUCATION
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3432
Practice Address - Country:US
Practice Address - Phone:847-316-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125074740207R00000X, 390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine