Provider Demographics
NPI: | 1013466598 |
---|---|
Name: | SHANMUGAM, JAYA PRASAD (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JAYA |
Middle Name: | PRASAD |
Last Name: | SHANMUGAM |
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: | 200 COMMODORE ST |
Mailing Address - Street 2: | |
Mailing Address - City: | PRATT |
Mailing Address - State: | KS |
Mailing Address - Zip Code: | 67124-2903 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 319-512-2693 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 203 WATSON ST STE 300 |
Practice Address - Street 2: | |
Practice Address - City: | PRATT |
Practice Address - State: | KS |
Practice Address - Zip Code: | 67124-3092 |
Practice Address - Country: | US |
Practice Address - Phone: | 620-672-1002 |
Practice Address - Fax: | 620-450-1741 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2016-09-26 |
Last Update Date: | 2021-04-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
LA | 310210 | 207XP3100X |
IA | R-10460 | 207XX0004X |
KS | 04-43900 | 207XX0005X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No | 207XP3100X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
No | 207XX0004X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |