Provider Demographics
NPI:1851786164
Name:SHANMUGAM, BALAJI
Entity Type:Individual
Prefix:DR
First Name:BALAJI
Middle Name:
Last Name:SHANMUGAM
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 1:209 BELLE FONTAINE CIRCLE
Mailing Address - Street 2:SUITE #403
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746
Mailing Address - Country:US
Mailing Address - Phone:917-683-3516
Mailing Address - Fax:
Practice Address - Street 1:209 BELLE FONTAINE CIR
Practice Address - Street 2:SUITE #403
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746
Practice Address - Country:US
Practice Address - Phone:917-683-3516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME154696207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology