Provider Demographics
NPI:1902926827
Name:DAS, SHANTHA (MD)
Entity Type:Individual
Prefix:
First Name:SHANTHA
Middle Name:
Last Name:DAS
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 1:150 KINGSLEY LN
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4602
Mailing Address - Country:US
Mailing Address - Phone:757-889-5157
Mailing Address - Fax:
Practice Address - Street 1:150 KINGSLEY LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4602
Practice Address - Country:US
Practice Address - Phone:757-889-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1902926827Medicaid
VA016198R53Medicare PIN
VA1902926827Medicaid
VAP00478566Medicare PIN