Provider Demographics
NPI:1306040712
Name:EHSANI, SHAUN (MD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:EHSANI
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 1:2682 MONTROSE PL
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-2143
Mailing Address - Country:US
Mailing Address - Phone:310-614-6459
Mailing Address - Fax:
Practice Address - Street 1:5333 HOLLISTER AVE STE 110
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93111-2379
Practice Address - Country:US
Practice Address - Phone:805-683-0055
Practice Address - Fax:805-683-0149
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA99065AMedicare PIN
CAP00690488OtherRAILROAD MEDICARE