1063646651 NPI number — DR. SHOBANA SAMPATH VANKIPURAM MD

Table of content: DR. SHOBANA SAMPATH VANKIPURAM MD (NPI 1063646651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063646651 NPI number — DR. SHOBANA SAMPATH VANKIPURAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANKIPURAM
Provider First Name:
SHOBANA
Provider Middle Name:
SAMPATH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ARVIND
Provider Other First Name:
SHOBANA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063646651
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 TREAT BLVD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94597-2168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 SAN RAMON VALLEY BLVD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94526-4036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-837-1044
Provider Business Practice Location Address Fax Number:
925-837-1055
Provider Enumeration Date:
05/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MT-193076 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: A116787 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MT-193076 . This is a "LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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