Provider Demographics
NPI:1457977332
Name:SHANKER, PRAJWAL (MD)
Entity type:Individual
Prefix:MR
First Name:PRAJWAL
Middle Name:
Last Name:SHANKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HURLEY PLAZA
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503
Mailing Address - Country:US
Mailing Address - Phone:810-262-9000
Mailing Address - Fax:
Practice Address - Street 1:1 HURLEY PLAZA
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503
Practice Address - Country:US
Practice Address - Phone:810-262-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2024-06-21
Deactivation Date:2022-01-18
Deactivation Code:
Reactivation Date:2022-02-11
Provider Licenses
StateLicense IDTaxonomies
MI5315249348208000000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program