Provider Demographics
NPI:1467548305
Name:SHAO, MAOGANG (MD)
Entity Type:Individual
Prefix:
First Name:MAOGANG
Middle Name:
Last Name:SHAO
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 1:8510 BALBOA BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325
Mailing Address - Country:US
Mailing Address - Phone:818-637-2000
Mailing Address - Fax:818-654-3417
Practice Address - Street 1:8510 BALBOA BLVD
Practice Address - Street 2:STE 150
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325
Practice Address - Country:US
Practice Address - Phone:818-637-2000
Practice Address - Fax:818-654-3417
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A728220Medicaid
CAA72822Medicare ID - Type Unspecified
CAH25882Medicare UPIN