Provider Demographics
NPI:1063646651
Name:VANKIPURAM, SHOBANA SAMPATH (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOBANA
Middle Name:SAMPATH
Last Name:VANKIPURAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHOBANA
Other - Middle Name:
Other - Last Name:ARVIND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1450 TREAT BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:907 SAN RAMON VALLEY BLVD
Practice Address - Street 2:STE 104
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4036
Practice Address - Country:US
Practice Address - Phone:925-837-1044
Practice Address - Fax:925-837-1055
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT-193076207Q00000X
CAA116787207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMT-193076OtherLICENSE