Provider Demographics
NPI:1407804974
Name:SHAVELSON, LONNY J (MD)
Entity Type:Individual
Prefix:DR
First Name:LONNY
Middle Name:J
Last Name:SHAVELSON
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 1:1030 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-3730
Mailing Address - Country:US
Mailing Address - Phone:510-238-5400
Mailing Address - Fax:510-238-5437
Practice Address - Street 1:1030 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-3730
Practice Address - Country:US
Practice Address - Phone:510-238-5400
Practice Address - Fax:510-238-5437
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37055207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G370550Medicaid
E74567Medicare UPIN
CA00G370550Medicare ID - Type Unspecified