Basic Information
| Provider Information | |||||||||
| NPI: | 1174592893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANKARIAH | ||||||||
| FirstName: | LAKSHMI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 SOUTH DRIVE | ||||||||
| Address2: | SUITE 131 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897795250 | ||||||||
| FaxNumber: | 9897795251 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 SOUTH DRIVE | ||||||||
| Address2: | SUITE 131 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897795250 | ||||||||
| FaxNumber: | 9897795251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301066496 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4381630 | 05 | MI | MEDICAID |