Provider Demographics
NPI:1902047814
Name:JOLLY, SHASHANK (MD)
Entity Type:Individual
Prefix:MR
First Name:SHASHANK
Middle Name:
Last Name:JOLLY
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 1:46689 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-7238
Mailing Address - Country:US
Mailing Address - Phone:408-389-8774
Mailing Address - Fax:408-516-9377
Practice Address - Street 1:8075 N SHADELAND AVE STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2694
Practice Address - Country:US
Practice Address - Phone:317-621-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430577208G00000X
CAA126261208G00000X
ND11204208G00000X
IN01081142A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA126261OtherSTATE LICENSE
MN1902047814Medicaid
MN1902047814Medicaid