Provider Demographics
NPI:1699722140
Name:SHIDHAM, SHUBHANGI G (MD)
Entity type:Individual
Prefix:DR
First Name:SHUBHANGI
Middle Name:G
Last Name:SHIDHAM
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 1:2226 PICKET POST LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2918
Mailing Address - Country:US
Mailing Address - Phone:614-549-0952
Mailing Address - Fax:
Practice Address - Street 1:420 N JAMES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-1834
Practice Address - Country:US
Practice Address - Phone:614-257-5727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085894207R00000X
OH35.085894207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI41469Medicare UPIN