Provider Demographics
NPI:1801903125
Name:MUKHOPADHYAY, SHANTASRI (MD)
Entity type:Individual
Prefix:DR
First Name:SHANTASRI
Middle Name:
Last Name:MUKHOPADHYAY
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 1:2706 CREEK SIDE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3145
Mailing Address - Country:US
Mailing Address - Phone:254-743-0335
Mailing Address - Fax:254-743-0178
Practice Address - Street 1:1901 S 1ST ST
Practice Address - Street 2:WOMEN CLINIC
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7451
Practice Address - Country:US
Practice Address - Phone:254-743-0441
Practice Address - Fax:254-743-0178
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK6170OtherTEXAS LICENSE