Provider Demographics
NPI:1073509311
Name:SHAKER, MANGALA C (MD)
Entity Type:Individual
Prefix:DR
First Name:MANGALA
Middle Name:C
Last Name:SHAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6833 INDIANA AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506
Mailing Address - Country:US
Mailing Address - Phone:951-781-4645
Mailing Address - Fax:951-231-9220
Practice Address - Street 1:6833 INDIANA AVE
Practice Address - Street 2:STE 101
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4223
Practice Address - Country:US
Practice Address - Phone:951-781-4645
Practice Address - Fax:877-904-9798
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A432250Medicaid
A29676Medicare UPIN
CA00A432250Medicaid