Provider Demographics
NPI:1225047301
Name:SHANTHA, ANAND T (MD)
Entity Type:Individual
Prefix:
First Name:ANAND
Middle Name:T
Last Name:SHANTHA
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 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:119 N PARK TRL
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7373
Practice Address - Country:US
Practice Address - Phone:770-389-3739
Practice Address - Fax:770-389-6565
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050677208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA340020189OtherRAILROAD MEDICARE
GA000972804AMedicaid
GABS6703309OtherDEA
GA000972804AMedicaid
GA340020189OtherRAILROAD MEDICARE