Provider Demographics
NPI:1710099379
Name:SHANKAR, STUTI (MD)
Entity Type:Individual
Prefix:DR
First Name:STUTI
Middle Name:
Last Name:SHANKAR
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 1:1350 S SUNNY SLOPE RD
Mailing Address - Street 2:SUNNYSLOPE PRIMARY CARE CLINIC
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-7060
Mailing Address - Country:US
Mailing Address - Phone:414-805-9600
Mailing Address - Fax:414-805-9645
Practice Address - Street 1:1350 S SUNNY SLOPE RD
Practice Address - Street 2:SUNNYSLOPE PRIMARY CARE CLINIC
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-7060
Practice Address - Country:US
Practice Address - Phone:414-805-9600
Practice Address - Fax:414-805-9645
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064047207R00000X
WI50450207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710099379Medicaid
0-604-328-5OtherECFMG NUMBER
WI680860693Medicare PIN
0-604-328-5OtherECFMG NUMBER
I69464Medicare UPIN