Provider Demographics
NPI:1811349822
Name:SHANMUGAM, KRUTHIKA (MD)
Entity type:Individual
Prefix:
First Name:KRUTHIKA
Middle Name:
Last Name:SHANMUGAM
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 1:2728 PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3228
Mailing Address - Country:US
Mailing Address - Phone:805-309-9104
Mailing Address - Fax:
Practice Address - Street 1:2728 PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3228
Practice Address - Country:US
Practice Address - Phone:661-916-4352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301110579207R00000X
WI75814-202084N0400X
IN01086106A2084N0400X
NJ25MA111673002084N0400X
MI43015019832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine