Provider Demographics
NPI:1376614818
Name:SHAH, HITENDRA H (MD)
Entity Type:Individual
Prefix:MR
First Name:HITENDRA
Middle Name:H
Last Name:SHAH
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 1:23341 GOLDEN SPRINGS DR
Mailing Address - Street 2:# 210
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2058
Mailing Address - Country:US
Mailing Address - Phone:909-860-2610
Mailing Address - Fax:
Practice Address - Street 1:23341 GOLDEN SPRINGS DR
Practice Address - Street 2:# 210
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2058
Practice Address - Country:US
Practice Address - Phone:909-860-2610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A366381Medicaid
CA00A366381Medicare ID - Type Unspecified
CA00A366381Medicaid