Provider Demographics
NPI:1366909657
Name:SHIRAVANTHE, SUSHMA RAO (BS, PHARMD, BCPS)
Entity type:Individual
Prefix:DR
First Name:SUSHMA
Middle Name:RAO
Last Name:SHIRAVANTHE
Suffix:
Gender:F
Credentials:BS, PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 ASPEN PL
Mailing Address - Street 2:
Mailing Address - City:EAST PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-1348
Mailing Address - Country:US
Mailing Address - Phone:248-767-4249
Mailing Address - Fax:
Practice Address - Street 1:3801 MIRANDA AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1207
Practice Address - Country:US
Practice Address - Phone:650-493-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026674A183500000X, 1835P1200X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty