Provider Demographics
NPI:1164431318
Name:SHANKAR, JAY ERIAH (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ERIAH
Last Name:SHANKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12675 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5878
Mailing Address - Country:US
Mailing Address - Phone:760-241-3306
Mailing Address - Fax:760-241-5037
Practice Address - Street 1:12675 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5878
Practice Address - Country:US
Practice Address - Phone:760-241-3306
Practice Address - Fax:760-241-5037
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40224207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ26953ZOtherGROUP ID
00A402240OtherPPIN
00A402240OtherPPIN