Provider Demographics
NPI:1275646952
Name:SHAMSID-DEEN, SHAFEEQ S (MD)
Entity Type:Individual
Prefix:
First Name:SHAFEEQ
Middle Name:S
Last Name:SHAMSID-DEEN
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 1:1000 SAN GABRIEL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-4394
Mailing Address - Country:US
Mailing Address - Phone:877-358-5841
Mailing Address - Fax:323-248-7044
Practice Address - Street 1:5970 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001
Practice Address - Country:US
Practice Address - Phone:323-234-3280
Practice Address - Fax:323-234-3493
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA952662606OtherTAX ID #
CAG36419OtherLICENSE
CAA91779Medicare UPIN
CAW11570CMedicare ID - Type UnspecifiedMEDICARE GR #