Basic Information
| Provider Information | |||||||||
| NPI: | 1760034367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANCHEGOWDA | ||||||||
| FirstName: | SHASHIDHAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 W MARKHAM ST # 783 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015265148 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 W MARKHAM ST # 515 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016866114 | ||||||||
| FaxNumber: | 5016868139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2019 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207LC0200X | E-15663 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207L00000X | E-15663 | AR | N | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.