Provider Demographics
NPI:1255313508
Name:DANIEL, SHANTHINI AMBROSE (MD)
Entity Type:Individual
Prefix:
First Name:SHANTHINI
Middle Name:AMBROSE
Last Name:DANIEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 S HEALTH PKWY
Mailing Address - Street 2:SUITE L-7
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-9387
Mailing Address - Country:US
Mailing Address - Phone:269-273-9723
Mailing Address - Fax:269-273-9746
Practice Address - Street 1:119 S KALAMAZOO ST
Practice Address - Street 2:
Practice Address - City:WHITE PIGEON
Practice Address - State:MI
Practice Address - Zip Code:49099-8149
Practice Address - Country:US
Practice Address - Phone:269-483-7624
Practice Address - Fax:269-483-7905
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041793208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4262684 10Medicaid
MI4262684 10Medicaid