Provider Demographics
NPI:1235101437
Name:SHI, GARY G (MD, PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:G
Last Name:SHI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 NEW YORK RANCH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-9328
Mailing Address - Country:US
Mailing Address - Phone:209-257-0292
Mailing Address - Fax:209-257-0676
Practice Address - Street 1:617 NEW YORK RANCH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9328
Practice Address - Country:US
Practice Address - Phone:209-257-0292
Practice Address - Fax:209-257-0676
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92230207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92230OtherMEDICAL LICENSE