Provider Demographics
NPI:1447308689
Name:SHANBHAG, ASHISH GAJANAN (MD)
Entity type:Individual
Prefix:DR
First Name:ASHISH
Middle Name:GAJANAN
Last Name:SHANBHAG
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:PO BOX 6012
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-6012
Mailing Address - Country:US
Mailing Address - Phone:864-278-6006
Mailing Address - Fax:864-278-6007
Practice Address - Street 1:14605 POTOMAC BRANCH DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:703-738-4371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19477207T00000X, 208100000X, 2081P2900X, 2081S0010X
VA0101252651208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC722-522Medicaid
SC194774Medicaid
SC194774Medicaid
SC722-522Medicaid