Basic Information
| Provider Information | |||||||||
| NPI: | 1750398897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHILPA | ||||||||
| FirstName: | MYSORE | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 TREAT BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945972168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259522888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1220 ROSSMOOR PKWY | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945952501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259473393 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 02/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A109570 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 373737 | 05 | AZ | MEDICAID | ZZZ47768Z | 01 | CA | MEDICARE | OTHER | 433061 | 05 | AZ | MEDICAID |