Provider Demographics
NPI:1821257981
Name:TANNAN, SHRUTI CHUDASAMA (MD)
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:CHUDASAMA
Last Name:TANNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:10208 CERNY ST STE 204
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-7885
Practice Address - Country:US
Practice Address - Phone:919-797-0996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00943208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery