Provider Demographics
NPI:1346237013
Name:SHANTHA, DEVENDRA T (MD)
Entity Type:Individual
Prefix:DR
First Name:DEVENDRA
Middle Name:T
Last Name:SHANTHA
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 1:706 HOLLYWOOD ST.
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302
Mailing Address - Country:US
Mailing Address - Phone:770-330-5684
Mailing Address - Fax:864-560-6276
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6122
Practice Address - Fax:864-560-6276
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19132207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC191321Medicaid
SC191321Medicaid