Provider Demographics
NPI:1356522718
Name:LAKSHMANAN, SHANMUGAM (MD)
Entity type:Individual
Prefix:DR
First Name:SHANMUGAM
Middle Name:
Last Name:LAKSHMANAN
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 1:111 E ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-2902
Mailing Address - Country:US
Mailing Address - Phone:618-548-5061
Mailing Address - Fax:618-548-5079
Practice Address - Street 1:111 E ROGERS ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-2902
Practice Address - Country:US
Practice Address - Phone:618-548-5061
Practice Address - Fax:618-548-5079
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
200771Medicare UPIN
IL636120Medicare PIN