Provider Demographics
NPI:1396768958
Name:KUMAR, SHANTHA (MD)
Entity type:Individual
Prefix:DR
First Name:SHANTHA
Middle Name:
Last Name:KUMAR
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 1:99 S GOLD DR
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-5030
Mailing Address - Country:US
Mailing Address - Phone:480-962-0101
Mailing Address - Fax:480-962-0202
Practice Address - Street 1:99 S GOLD DR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-5035
Practice Address - Country:US
Practice Address - Phone:480-962-0101
Practice Address - Fax:480-962-0202
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23951174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ376592OtherAHCCCS
AZAZ 0742840OtherBC/BS
AZ376592OtherAHCCCS
AZF78276Medicare UPIN
AZZ139224Medicare PIN
AZAZ 0742840OtherBC/BS
AZZ76442Medicare PIN