Basic Information
| Provider Information | |||||||||
| NPI: | 1902805898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NILAKANTAN | ||||||||
| FirstName: | SHANTI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 PALO VERDE AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908151552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624292473 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2925 PALO VERDE AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908151552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624292473 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A38477 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | A38477 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0300X | A38477 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A384770 | 01 | CA | MEDI CAL | OTHER |