Provider Demographics
NPI:1801990254
Name:SHASTRY, MANJALI SUSHIL (MD)
Entity type:Individual
Prefix:MRS
First Name:MANJALI
Middle Name:SUSHIL
Last Name:SHASTRY
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 1:1787 S M 52
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-9201
Mailing Address - Country:US
Mailing Address - Phone:989-729-4600
Mailing Address - Fax:989-725-5760
Practice Address - Street 1:1787 S M 52
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-9201
Practice Address - Country:US
Practice Address - Phone:989-729-4600
Practice Address - Fax:989-725-5760
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069446208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4552316Medicaid