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 1:2431 E 61ST ST STE 500
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-1208
Mailing Address - Country:US
Mailing Address - Phone:918-582-6800
Mailing Address - Fax:
Practice Address - Street 1:3400 E FRANK PHILLIPS BLVD STE 301
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2439
Practice Address - Country:US
Practice Address - Phone:918-582-6800
Practice Address - Fax:918-582-6060
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2024-11-07
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