Provider Demographics
NPI:1801855085
Name:SHASTRY, CHANDRA SHAKARA (MD)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:SHAKARA
Last Name:SHASTRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 SUMMIT CROSSING PL
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2104
Mailing Address - Country:US
Mailing Address - Phone:704-867-0735
Mailing Address - Fax:704-867-0738
Practice Address - Street 1:660 SUMMIT CROSSING PL
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2104
Practice Address - Country:US
Practice Address - Phone:704-867-0735
Practice Address - Fax:704-867-0738
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC24736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8975510Medicaid
NC8975510Medicaid
D33033Medicare UPIN