Provider Demographics
NPI:1518347210
Name:SHAH, SHRADDHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHRADDHA
Middle Name:
Last Name:SHAH
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 1:380 W CENTRAL AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3066
Mailing Address - Country:US
Mailing Address - Phone:714-203-1799
Mailing Address - Fax:714-203-1716
Practice Address - Street 1:380 W CENTRAL AVE STE 400
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3066
Practice Address - Country:US
Practice Address - Phone:714-203-1799
Practice Address - Fax:714-203-1716
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA151301207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program