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
StateLicense IDTaxonomies
LA310210207XP3100X
IAR-10460207XX0004X
KS04-43900207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery