Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0203X | Pediatric Critical Care Doctor | 54251 | TN |
NPI | 1053670273 |
---|---|
Provider Name | Dr. Shantaveer Gangu |
First Address | Memphis, TN 38105-4625 |
Second Address | Memphis, TN 38103-2816 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2012 |
Last Update Date | 29/06/2016 |