Provider Demographics
NPI:1790772838
Name:SHANKAR, PRITHVI NAMBALAT (MD)
Entity Type:Individual
Prefix:
First Name:PRITHVI
Middle Name:NAMBALAT
Last Name:SHANKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579225
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-9225
Mailing Address - Country:US
Mailing Address - Phone:209-578-1600
Mailing Address - Fax:209-578-1088
Practice Address - Street 1:400 E ORANGEBURG AVE
Practice Address - Street 2:STE 3
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5342
Practice Address - Country:US
Practice Address - Phone:209-578-1600
Practice Address - Fax:209-578-1088
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00266668OtherRAILROAD MEDICARE
CAP00266668OtherRAILROAD MEDICARE
CAI36323Medicare UPIN