Provider Demographics
NPI:1306852975
Name:BINDU, SHANTALA (MD)
Entity Type:Individual
Prefix:
First Name:SHANTALA
Middle Name:
Last Name:BINDU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANTALA
Other - Middle Name:
Other - Last Name:VIJAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4230 BURNHAM AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119
Mailing Address - Country:US
Mailing Address - Phone:702-733-7866
Mailing Address - Fax:702-733-8862
Practice Address - Street 1:4230 BURNHAM AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119
Practice Address - Country:US
Practice Address - Phone:702-733-7866
Practice Address - Fax:702-792-1319
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11103207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I24614Medicare UPIN
100196Medicare ID - Type Unspecified