Provider Demographics
NPI:1801995535
Name:SHANKARAIAH, NAGARAKERE R (MD)
Entity type:Individual
Prefix:
First Name:NAGARAKERE
Middle Name:R
Last Name:SHANKARAIAH
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 1:3112 S CONGRESS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461
Mailing Address - Country:US
Mailing Address - Phone:561-964-0110
Mailing Address - Fax:561-964-0401
Practice Address - Street 1:3112 S CONGRESS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461
Practice Address - Country:US
Practice Address - Phone:561-964-0110
Practice Address - Fax:561-964-0401
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064222302Medicaid
FL250558400Medicaid
FL064222302Medicaid