Provider Demographics
NPI:1487018586
Name:SHIVAJI, SHANTI MANGALASSERIL (MD)
Entity Type:Individual
Prefix:
First Name:SHANTI
Middle Name:MANGALASSERIL
Last Name:SHIVAJI
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 1:1730 BALDWIN DR
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-5048
Mailing Address - Country:US
Mailing Address - Phone:703-442-0486
Mailing Address - Fax:
Practice Address - Street 1:510 N ELAM AVE STE 101
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1135
Practice Address - Country:US
Practice Address - Phone:336-854-8800
Practice Address - Fax:336-834-0595
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC202002975207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program