Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | DRP1797 | FL |
NPI | 1245716661 |
---|---|
Provider Name | Shanker Venkateshwaran JR. |
First Address | Gainesville, FL 32610-3006 |
Second Address | Gainesville, FL 32610-3006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2018 |
Last Update Date | 18/07/2018 |