Provider Demographics
NPI:1760128961
Name:SHANKAR, PREM (MD)
Entity type:Individual
Prefix:
First Name:PREM
Middle Name:
Last Name:SHANKAR
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 1:6001 KYLE PKWY
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-6112
Mailing Address - Country:US
Mailing Address - Phone:512-504-5000
Mailing Address - Fax:
Practice Address - Street 1:6001 KYLE PKWY
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6112
Practice Address - Country:US
Practice Address - Phone:512-504-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2025-07-19
Deactivation Date:2022-12-21
Deactivation Code:
Reactivation Date:2023-01-06
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXV6698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program