Provider Demographics
NPI:1750398897
Name:SHILPA, MYSORE S (MD)
Entity type:Individual
Prefix:
First Name:MYSORE
Middle Name:S
Last Name:SHILPA
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 1:1450 TREAT BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:925-952-2888
Mailing Address - Fax:
Practice Address - Street 1:1220 ROSSMOOR PKWY
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-2501
Practice Address - Country:US
Practice Address - Phone:925-947-3393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109570207R00000X
AZ41171207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ373737Medicaid
CAZZZ47768ZOtherMEDICARE
AZ433061Medicaid
Z21113Medicare Oscar/Certification
031824Medicare Oscar/Certification
Z125429Medicare PIN
Z125262Medicare PIN
031806Medicare Oscar/Certification
Z21116Medicare PIN
Z125263Medicare PIN
AZ433061Medicaid
031805Medicare Oscar/Certification
Z125264Medicare PIN
031822Medicare Oscar/Certification
AZI50769Medicare UPIN
NV102185Medicare ID - Type Unspecified
Z21115Medicare Oscar/Certification
031823Medicare Oscar/Certification