Provider Demographics
NPI:1023198322
Name:YERMIAN, SHOALEH (DO)
Entity Type:Individual
Prefix:DR
First Name:SHOALEH
Middle Name:
Last Name:YERMIAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5727
Mailing Address - Country:US
Mailing Address - Phone:323-581-6588
Mailing Address - Fax:323-581-1812
Practice Address - Street 1:2402 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5727
Practice Address - Country:US
Practice Address - Phone:323-581-6588
Practice Address - Fax:323-581-1812
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078550OtherFPACT
CAGR0078550OtherCHDP
CAGR0078550Medicaid
CAGR0078550OtherBCEDP
CAGR0078550OtherBCEDP
CAGR0078550Medicaid