Provider Demographics
NPI:1477174084
Name:NANDAKUMAR, SHANKAR MULLOTH
Entity Type:Individual
Prefix:
First Name:SHANKAR
Middle Name:MULLOTH
Last Name:NANDAKUMAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 EANESWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6716
Mailing Address - Country:US
Mailing Address - Phone:512-923-9668
Mailing Address - Fax:
Practice Address - Street 1:7877 WILLOW CHASE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-5934
Practice Address - Country:US
Practice Address - Phone:832-869-4818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU51782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program