Provider Demographics
NPI:1437352739
Name:FREYALDENHOVEN, MISHA SHAH (MD)
Entity Type:Individual
Prefix:
First Name:MISHA
Middle Name:SHAH
Last Name:FREYALDENHOVEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MISHA
Other - Middle Name:
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1288 MORRO ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6302
Mailing Address - Country:US
Mailing Address - Phone:805-543-1233
Mailing Address - Fax:805-547-1179
Practice Address - Street 1:1288 MORRO ST STE 200
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6302
Practice Address - Country:US
Practice Address - Phone:805-543-1233
Practice Address - Fax:805-547-1179
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50374174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC50374OtherSTATE LICENSE
CAC50374OtherSTATE LICENSE
CAG14503Medicare UPIN