Provider Demographics
NPI:1053669390
Name:SHEN, BRENDA (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:SHEN
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 1:520 N PROSPECT AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3041
Mailing Address - Country:US
Mailing Address - Phone:310-376-8816
Mailing Address - Fax:
Practice Address - Street 1:520 N PROSPECT AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3041
Practice Address - Country:US
Practice Address - Phone:310-376-8816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine