Provider Demographics
NPI:1942400759
Name:BISHWAL, SHANTANU (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANTANU
Middle Name:
Last Name:BISHWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 BALTIMORE DR
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-7900
Mailing Address - Country:US
Mailing Address - Phone:570-808-6111
Mailing Address - Fax:570-808-6348
Practice Address - Street 1:675 BALTIMORE DR
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-7900
Practice Address - Country:US
Practice Address - Phone:570-808-6111
Practice Address - Fax:570-808-6348
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD436784207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology