Provider Demographics
NPI:1568752483
Name:SHAMALA MD PHYSICIAN PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHAMALA MD PHYSICIAN PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHANASUNDARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-370-0200
Mailing Address - Street 1:555 KNOWLES DRIVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032
Mailing Address - Country:US
Mailing Address - Phone:408-370-0200
Mailing Address - Fax:408-370-0202
Practice Address - Street 1:555 KNOWLES DRIVE
Practice Address - Street 2:SUITE 109
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032
Practice Address - Country:US
Practice Address - Phone:408-370-0200
Practice Address - Fax:408-370-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
EU830AMedicare PIN