Provider Demographics
NPI:1740219807
Name:NEERUKONDA, SHANTI K (MD)
Entity Type:Individual
Prefix:
First Name:SHANTI
Middle Name:K
Last Name:NEERUKONDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHANTI
Other - Middle Name:K
Other - Last Name:NEERUKONDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA
Mailing Address - Street 1:501 GOLDER AVE STE 202-A
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4411
Mailing Address - Country:US
Mailing Address - Phone:432-333-6200
Mailing Address - Fax:432-333-6213
Practice Address - Street 1:501 GOLDER AVE STE 202-A
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4411
Practice Address - Country:US
Practice Address - Phone:432-333-6200
Practice Address - Fax:432-333-6213
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0148207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$OtherSSN
TX00752GMedicare PIN