Provider Demographics
NPI:1588636450
Name:NAGARAKERE SHANKARAIAH MD
Entity Type:Organization
Organization Name:NAGARAKERE SHANKARAIAH MD
Other - Org Name:LAKE WORTH PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NAGARAKERE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANKARAIAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-964-0110
Mailing Address - Street 1:3112 S CONGRESS AVE
Mailing Address - Street 2:STE A
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461
Mailing Address - Country:US
Mailing Address - Phone:561-964-0110
Mailing Address - Fax:561-964-0401
Practice Address - Street 1:3112 S CONGRESS AVE
Practice Address - Street 2:STE A
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461
Practice Address - Country:US
Practice Address - Phone:561-964-0110
Practice Address - Fax:561-964-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E61835Medicare UPIN