Provider Demographics
NPI:1518930486
Name:NANJUNDASWAMY, SHASHIDHARA (MD)
Entity Type:Individual
Prefix:
First Name:SHASHIDHARA
Middle Name:
Last Name:NANJUNDASWAMY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FL
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-5532
Mailing Address - Fax:
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:SUITE 230S
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-368-3150
Practice Address - Fax:508-368-3152
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2253272084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2115646Medicaid
MAA40062Medicare PIN
MA2115646Medicaid