Provider Demographics
NPI:1881793495
Name:PURUSHOTHAM, SHANTA ARUMBAKAM (MD)
Entity type:Individual
Prefix:MISS
First Name:SHANTA
Middle Name:ARUMBAKAM
Last Name:PURUSHOTHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:711 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-2842
Mailing Address - Country:US
Mailing Address - Phone:352-799-0135
Mailing Address - Fax:352-754-5394
Practice Address - Street 1:711 HARVARD STREET
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601
Practice Address - Country:US
Practice Address - Phone:352-799-0135
Practice Address - Fax:352-754-5394
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66516207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F49372Medicare UPIN