Provider Demographics
NPI:1053643171
Name:DR MONA SHAH PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DR MONA SHAH PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-548-0201
Mailing Address - Street 1:1600 S GAFFEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-4628
Mailing Address - Country:US
Mailing Address - Phone:310-548-0201
Mailing Address - Fax:310-547-3340
Practice Address - Street 1:1600 S GAFFEY ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-4628
Practice Address - Country:US
Practice Address - Phone:310-548-0201
Practice Address - Fax:310-547-3340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-01
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty