Provider Demographics
NPI:1548296429
Name:SHANKAR, K J (MD)
Entity type:Individual
Prefix:DR
First Name:K
Middle Name:J
Last Name:SHANKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KOOVAPUDI
Other - Middle Name:JAYARAM
Other - Last Name:SHANKAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:13737 NOEL RD STE 1500
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1331
Mailing Address - Country:US
Mailing Address - Phone:214-217-1951
Mailing Address - Fax:866-858-0622
Practice Address - Street 1:3301 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2908
Practice Address - Country:US
Practice Address - Phone:682-509-5012
Practice Address - Fax:682-509-6511
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA249826208M00000X, 207R00000X
TN43941208M00000X, 207R00000X
TXM3385207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1512300Medicaid
TN1509009Medicaid
NC1548296429Medicaid
UT1548296429Medicaid
TN1512300Medicaid
TN30022741Medicare PIN