Provider Demographics
NPI:1508934415
Name:SHAMS, TAHER A
Entity Type:Individual
Prefix:
First Name:TAHER
Middle Name:A
Last Name:SHAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34845 YUCAIPA BLVD.,
Mailing Address - Street 2:SUITE # A
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4237
Mailing Address - Country:US
Mailing Address - Phone:909-480-5691
Mailing Address - Fax:
Practice Address - Street 1:34845 YUCAIPA BLVD.,
Practice Address - Street 2:SUITE #A
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4237
Practice Address - Country:US
Practice Address - Phone:909-480-5691
Practice Address - Fax:909-790-5878
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41410208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A414100Medicaid
CA00A414100Medicaid
WA41410IMedicare ID - Type UnspecifiedPPIN NUMBER (GRP W14027)