Provider Demographics
NPI:1487612412
Name:SHANBHAG, PRAMILA GAJANAN (MD)
Entity type:Individual
Prefix:DR
First Name:PRAMILA
Middle Name:GAJANAN
Last Name:SHANBHAG
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 1:511 CROSS ANCHOR RD
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:SC
Mailing Address - Zip Code:29388-2328
Mailing Address - Country:US
Mailing Address - Phone:864-476-8195
Mailing Address - Fax:864-476-3084
Practice Address - Street 1:511 CROSS ANCHOR RD
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-2328
Practice Address - Country:US
Practice Address - Phone:864-476-8195
Practice Address - Fax:864-476-3084
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC117509Medicaid