Provider Demographics
NPI:1417967423
Name:THANGAM, SHANTHI (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHANTHI
Middle Name:
Last Name:THANGAM
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 1:419 N JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5124
Mailing Address - Country:US
Mailing Address - Phone:432-337-9000
Mailing Address - Fax:432-337-2545
Practice Address - Street 1:511 N ALLEGHANEY AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4405
Practice Address - Country:US
Practice Address - Phone:432-337-9000
Practice Address - Fax:432-337-2545
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK71112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046180802Medicaid
TXG84234Medicare UPIN