Provider Demographics
NPI:1285987552
Name:NUGURU, SHASHANK (MD)
Entity type:Individual
Prefix:
First Name:SHASHANK
Middle Name:
Last Name:NUGURU
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 1:120 STONEBRIDGE PKWY STE 320
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3769
Mailing Address - Country:US
Mailing Address - Phone:770-422-1372
Mailing Address - Fax:770-423-9651
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:UH 1501
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-948-1310
Practice Address - Fax:317-948-0503
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075577A207R00000X
GA90273207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201309900Medicaid
INP01551546Medicare PIN
IN068010161Medicare PIN