Provider Demographics
NPI:1356440887
Name:SRIKANTH, SHANKARAN (MD)
Entity Type:Individual
Prefix:
First Name:SHANKARAN
Middle Name:
Last Name:SRIKANTH
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 1:330 N WABASH
Mailing Address - Street 2:STE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1406 W BELLA DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5229
Practice Address - Country:US
Practice Address - Phone:765-660-7720
Practice Address - Fax:765-662-4493
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000742620OtherANTHEM
IN200192920BMedicaid
G95426Medicare UPIN
IN200192920BMedicaid