Provider Demographics
NPI:1144207002
Name:RHODES, SHANE DANIEL (DPM FACFAS)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:DANIEL
Last Name:RHODES
Suffix:
Gender:M
Credentials:DPM FACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25078 PEACHLAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2533
Mailing Address - Country:US
Mailing Address - Phone:661-799-3668
Mailing Address - Fax:661-799-3331
Practice Address - Street 1:25078 PEACHLAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2533
Practice Address - Country:US
Practice Address - Phone:661-799-3668
Practice Address - Fax:661-799-3331
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4094213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E40941Medicaid
E4094AMedicare ID - Type Unspecified
4785400001Medicare NSC
CAE40904Medicare PIN
CA000E40941Medicaid
CA6121950001Medicare NSC