Provider Demographics
NPI:1942236567
Name:KESAVULU, SHANTHA (MD)
Entity Type:Individual
Prefix:
First Name:SHANTHA
Middle Name:
Last Name:KESAVULU
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 1:4242 E SOUTHCROSS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78222-3728
Mailing Address - Country:US
Mailing Address - Phone:210-333-4638
Mailing Address - Fax:
Practice Address - Street 1:4242 E SOUTHCROSS BLVD STE 6
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-3728
Practice Address - Country:US
Practice Address - Phone:210-333-4638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXGO742208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics