Provider Demographics
NPI:1003922162
Name:SHAMBAN, AVA T (MD)
Entity Type:Individual
Prefix:
First Name:AVA
Middle Name:T
Last Name:SHAMBAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 SANTA MONICA BLVD STE 600E
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2166
Mailing Address - Country:US
Mailing Address - Phone:310-828-2282
Mailing Address - Fax:310-828-8504
Practice Address - Street 1:2021 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 600E
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-828-2282
Practice Address - Fax:310-828-8504
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50969207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE7567Medicare UPIN
CAW13960Medicare ID - Type Unspecified
E57567Medicare UPIN