Provider Demographics
NPI:1194715334
Name:SHIVANANJAPPA, SHANTHALA J (MD)
Entity type:Individual
Prefix:DR
First Name:SHANTHALA
Middle Name:J
Last Name:SHIVANANJAPPA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 372
Mailing Address - Street 2:C/O MA ANESTHESIA CORP.
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-0372
Mailing Address - Country:US
Mailing Address - Phone:781-341-3966
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:50 STANIFORD STREET
Practice Address - Street 2:C/O MA ANESTHESIA CORP
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-665-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA217119207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2030331Medicaid
MA467250OtherTUFTS HEALTH PLAN
MAJ26878OtherBCBS MA
H44190Medicare UPIN
MA467250OtherTUFTS HEALTH PLAN