Provider Demographics
NPI:1497069702
Name:CHANDRASHEKHAR VIJAYALAKSHMI, SHRUTHI MANJUNATHA (MD)
Entity type:Individual
Prefix:DR
First Name:SHRUTHI MANJUNATHA
Middle Name:
Last Name:CHANDRASHEKHAR VIJAYALAKSHMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHRUTHI MANJUNATHA
Other - Middle Name:
Other - Last Name:CHANDRASHEKHAR VIJAYALAKSHMI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4191 INNSLAKE DR STE 211
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3324
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:4191 INNSLAKE DR STE 211
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3324
Practice Address - Country:US
Practice Address - Phone:804-828-3144
Practice Address - Fax:804-628-7104
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV4080BMedicare PIN