Provider Demographics
NPI:1881893121
Name:SHANKAR, SANJAY VASUDEVAN (MD)
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:VASUDEVAN
Last Name:SHANKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SANJAY
Other - Middle Name:SHANKAR
Other - Last Name:VASUDEVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9520 W PALM LN STE 150
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-4454
Mailing Address - Country:US
Mailing Address - Phone:602-584-5444
Mailing Address - Fax:602-584-6202
Practice Address - Street 1:9520 W PALM LN STE 150
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-4454
Practice Address - Country:US
Practice Address - Phone:602-584-5444
Practice Address - Fax:602-584-6202
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ54987207RI0011X, 207RC0000X, 207RC0000X, 207RI0011X
PAMD428566207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ312717Medicaid
AZZ208684OtherMEDICARE
AZZ208684OtherMEDICARE
OH4300781Medicare PIN
WV4307191Medicare PIN