Provider Demographics
NPI:1386603710
Name:SHANMUGAM, CHAMUNDAMBIKA (MD)
Entity type:Individual
Prefix:
First Name:CHAMUNDAMBIKA
Middle Name:
Last Name:SHANMUGAM
Suffix:
Gender:F
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:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-0488
Mailing Address - Country:US
Mailing Address - Phone:336-635-6809
Mailing Address - Fax:336-627-0778
Practice Address - Street 1:520 S VAN BUREN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5042
Practice Address - Country:US
Practice Address - Phone:336-635-6809
Practice Address - Fax:336-635-6862
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114856208000000X
NC2012-01298208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114856Medicaid
NC174NHOtherNC BLUE CROSS BLUE SHIELD
NC5921210Medicaid
IL212841Medicare PIN
NC174NHOtherNC BLUE CROSS BLUE SHIELD
G63391Medicare UPIN