Provider Demographics
NPI:1609311240
Name:SHESHAM, SHASHANKA
Entity Type:Individual
Prefix:
First Name:SHASHANKA
Middle Name:
Last Name:SHESHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7345 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1737
Mailing Address - Country:US
Mailing Address - Phone:317-388-0800
Mailing Address - Fax:317-388-0805
Practice Address - Street 1:7345 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1737
Practice Address - Country:US
Practice Address - Phone:317-388-0800
Practice Address - Fax:317-388-0805
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16035225100000X
MD25749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist