Provider Demographics
NPI:1538470604
Name:MUNAGALA, SHAILAJA
Entity Type:Individual
Prefix:
First Name:SHAILAJA
Middle Name:
Last Name:MUNAGALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 ALABAMA STREET
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-3532
Mailing Address - Country:US
Mailing Address - Phone:920-530-5302
Mailing Address - Fax:
Practice Address - Street 1:1910 ALABAMA STREET
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-3532
Practice Address - Country:US
Practice Address - Phone:920-530-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5643020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1538470604Medicaid