Provider Demographics
NPI:1104822055
Name:MAHAPATRA, SHAKTI AVA (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHAKTI
Middle Name:AVA
Last Name:MAHAPATRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S PALM CANYON DR
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-7303
Mailing Address - Country:US
Mailing Address - Phone:760-773-4560
Mailing Address - Fax:760-773-4561
Practice Address - Street 1:415 S PALM CANYON DR
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-7303
Practice Address - Country:US
Practice Address - Phone:760-773-4560
Practice Address - Fax:760-773-4561
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37578207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A37580Medicaid
CA00A375780Medicare PIN
A88920Medicare UPIN