Provider Demographics
NPI:1427431147
Name:KANDASWAMY, SHAKTHISHREE
Entity type:Individual
Prefix:
First Name:SHAKTHISHREE
Middle Name:
Last Name:KANDASWAMY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAKTHISHRI
Other - Middle Name:
Other - Last Name:KANDASWAMY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5601 W EUGIE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1258
Mailing Address - Country:US
Mailing Address - Phone:623-250-1419
Mailing Address - Fax:
Practice Address - Street 1:5601 W EUGIE AVE STE 204
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1258
Practice Address - Country:US
Practice Address - Phone:623-250-1419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125066454207R00000X
CAA157620208M00000X
AZ69856207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist