Provider Demographics
NPI:1336125178
Name:SHAPIRO, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:SHAPIRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:265 POSADA LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-4056
Mailing Address - Country:US
Mailing Address - Phone:805-239-1488
Mailing Address - Fax:805-227-0263
Practice Address - Street 1:265 POSADA LN
Practice Address - Street 2:SUITE C
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4056
Practice Address - Country:US
Practice Address - Phone:805-239-1488
Practice Address - Fax:805-227-0263
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA31431207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A314310OtherBLUE SHIELD PIN
CAP00092287OtherRAILROAD MEDICARE ID
CAA31431OtherCA MEDICAL LICENSE
CA10971743OtherCAQH NUMBER
CA4385363OtherAETNA PIN
CAA26479Medicare UPIN
CA4385363OtherAETNA PIN