Provider Demographics
NPI:1992238984
Name:SHAKYA, SAMPURNA (MD)
Entity type:Individual
Prefix:
First Name:SAMPURNA
Middle Name:
Last Name:SHAKYA
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 1:2422 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4985
Mailing Address - Country:US
Mailing Address - Phone:440-997-6980
Mailing Address - Fax:440-994-7514
Practice Address - Street 1:2422 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4985
Practice Address - Country:US
Practice Address - Phone:440-997-6980
Practice Address - Fax:440-994-7514
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.139245208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty