Provider Demographics
NPI:1871588731
Name:SUBRAMANIAN, SHYAMSUNDER (MD)
Entity type:Individual
Prefix:
First Name:SHYAMSUNDER
Middle Name:
Last Name:SUBRAMANIAN
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:530 W EATON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3400
Practice Address - Country:US
Practice Address - Phone:209-830-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC133248207RC0200X, 207RP1001X, 207RP1001X, 207RC0200X
OH35-080385207RP1001X
TXM2829207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050417Medicaid
PA100867463Medicaid
PA100867463Medicaid
OHP01061431Medicare PIN
OH0050417Medicaid
OHH038411Medicare PIN
OHH038410Medicare PIN
TX8G3785Medicare PIN