Provider Demographics
NPI:1467955401
Name:BATHULA, SHASHANK (DO)
Entity Type:Individual
Prefix:MR
First Name:SHASHANK
Middle Name:
Last Name:BATHULA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:SHASHANK
Other - Middle Name:P
Other - Last Name:BATHULA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5450 FORT ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-4601
Mailing Address - Country:US
Mailing Address - Phone:734-671-3800
Mailing Address - Fax:
Practice Address - Street 1:5450 FORT ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4601
Practice Address - Country:US
Practice Address - Phone:734-671-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151014660207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program