Provider Demographics
NPI:1225657364
Name:SHANKAR, KEITH BALRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:BALRAM
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:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-0488
Mailing Address - Country:US
Mailing Address - Phone:716-852-4772
Mailing Address - Fax:
Practice Address - Street 1:3898 VINEYARD DR STE 1
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-3559
Practice Address - Country:US
Practice Address - Phone:716-363-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2023-12-05
Deactivation Date:2022-01-10
Deactivation Code:
Reactivation Date:2022-01-25
Provider Licenses
StateLicense IDTaxonomies
NY326975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine