Provider Demographics
NPI:1386659811
Name:SHANMUGAM, AIYANADAR (MD FACE, FACE)
Entity Type:Individual
Prefix:DR
First Name:AIYANADAR
Middle Name:
Last Name:SHANMUGAM
Suffix:
Gender:M
Credentials:MD FACE, FACE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 ROCK PRAIRIE RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8306
Mailing Address - Country:US
Mailing Address - Phone:979-696-5663
Mailing Address - Fax:979-693-1274
Practice Address - Street 1:1602 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8306
Practice Address - Country:US
Practice Address - Phone:979-696-5663
Practice Address - Fax:979-693-1274
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74-2273494174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110539701Medicaid
TX00AQ85OtherBLUE CROSS BLUE SHIELD
TX00AQ85Medicare ID - Type Unspecified
TX110539701Medicaid