Provider Demographics
NPI:1255341798
Name:SHANTHA, SHANMUGAN (MD)
Entity type:Individual
Prefix:MS
First Name:SHANMUGAN
Middle Name:
Last Name:SHANTHA
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 1:7153 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-7431
Mailing Address - Country:US
Mailing Address - Phone:504-914-2908
Mailing Address - Fax:504-349-1668
Practice Address - Street 1:900 WILKINSON ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3533
Practice Address - Country:US
Practice Address - Phone:985-624-4450
Practice Address - Fax:985-624-4451
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD150R2084P0804X
LAMD.15098R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1422029Medicaid
LA1422029Medicaid
LAI46329Medicare ID - Type Unspecified