Provider Demographics
NPI:1356309504
Name:BAKIR, SHATHA (MD)
Entity Type:Individual
Prefix:
First Name:SHATHA
Middle Name:
Last Name:BAKIR
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 1:12550 HESPERIA RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5873
Mailing Address - Country:US
Mailing Address - Phone:760-241-6666
Mailing Address - Fax:760-241-7575
Practice Address - Street 1:19333 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-5148
Practice Address - Country:US
Practice Address - Phone:760-240-3784
Practice Address - Fax:760-247-4368
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49522207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF04000Medicare UPIN
CABY095YMedicare PIN