Healthcare Provider Details

I. General information

NPI: 1457977332
Provider Name (Legal Business Name): PRAJWAL SHANKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date: 01/18/2022
Reactivation Date: 02/11/2022

III. Provider practice location address

1 HURLEY PLAZA
FLINT MI
48503
US

IV. Provider business mailing address

1 HURLEY PLAZA
FLINT MI
48503
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-9000
  • Fax:
Mailing address:
  • Phone: 810-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5315249348
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5315249348
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: