Provider Demographics
NPI:1215148200
Name:SHANMUGAM, GANESH (MD)
Entity type:Individual
Prefix:DR
First Name:GANESH
Middle Name:
Last Name:SHANMUGAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 ROCK PRAIRIE RD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8306
Mailing Address - Country:US
Mailing Address - Phone:979-703-6112
Mailing Address - Fax:979-703-6649
Practice Address - Street 1:1602 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE 270
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8306
Practice Address - Country:US
Practice Address - Phone:979-703-6112
Practice Address - Fax:979-703-6649
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6388207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3201428Medicaid
TX281348YRDAMedicare PIN