Provider Demographics
NPI:1649263872
Name:SHASHIDHARA, MALERY (MD)
Entity type:Individual
Prefix:
First Name:MALERY
Middle Name:
Last Name:SHASHIDHARA
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 1:250 2ND ST E
Mailing Address - Street 2:STE 3E
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1029
Mailing Address - Country:US
Mailing Address - Phone:941-748-2417
Mailing Address - Fax:941-748-3694
Practice Address - Street 1:250 2ND ST E
Practice Address - Street 2:STE 3E
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1029
Practice Address - Country:US
Practice Address - Phone:941-748-2417
Practice Address - Fax:941-748-3694
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041924207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79772OtherBLUE CROSS BLUE SHIELD
656482OtherAETNA HMO
2905130OtherUNITED HEALTH CARE
4259049OtherAETNA PPO
D86374Medicare UPIN
4259049OtherAETNA PPO