Provider Demographics
NPI:1245245018
Name:SHALI, REYZAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:REYZAN
Middle Name:E
Last Name:SHALI
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 1:1926 VIA CTR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6056
Mailing Address - Country:US
Mailing Address - Phone:760-940-7000
Mailing Address - Fax:760-940-0042
Practice Address - Street 1:6185 PASEO DEL NORTE STE 100
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1152
Practice Address - Country:US
Practice Address - Phone:760-940-7000
Practice Address - Fax:760-940-0042
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A762300Medicaid
CA00A762300Medicaid
CAH94236Medicare UPIN