Provider Demographics
NPI:1386012888
Name:CHINICHIAN, SHIDEH (MD)
Entity Type:Individual
Prefix:
First Name:SHIDEH
Middle Name:
Last Name:CHINICHIAN
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1264 HAWKS FLIGHT CT STE 100
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9354
Practice Address - Country:US
Practice Address - Phone:916-939-8400
Practice Address - Fax:916-939-8971
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA138077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine