Provider Demographics
NPI:1568445815
Name:SHANKAR, KUPPE (MD)
Entity Type:Individual
Prefix:DR
First Name:KUPPE
Middle Name:
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 1:3811 WINDING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-1660
Mailing Address - Country:US
Mailing Address - Phone:916-734-3861
Mailing Address - Fax:
Practice Address - Street 1:2221 STOCKTON BLVD
Practice Address - Street 2:SUITEE 2112
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1418
Practice Address - Country:US
Practice Address - Phone:916-734-3861
Practice Address - Fax:916-734-3066
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24526208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAS5077955OtherDEA CERTIFICATE
CAAS5077955OtherDEA CERTIFICATE
CA00A245262Medicare PIN