Provider Demographics
NPI:1053429811
Name:KRISHNAMURTHI, SHAKUNTHALA (MD)
Entity type:Individual
Prefix:
First Name:SHAKUNTHALA
Middle Name:
Last Name:KRISHNAMURTHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VENGUSAMY
Other - Middle Name:
Other - Last Name:SHAKUNTHALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5839 STONE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45429
Mailing Address - Country:US
Mailing Address - Phone:937-438-8645
Mailing Address - Fax:
Practice Address - Street 1:5839 STONE LAKE DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45429
Practice Address - Country:US
Practice Address - Phone:937-438-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068097208000000X
MI4301062202208000000X
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics