Provider Demographics
NPI:1568758928
Name:SHAFFER, MIMI (MD)
Entity Type:Individual
Prefix:DR
First Name:MIMI
Middle Name:
Last Name:SHAFFER
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 1:1400 E PALOMAR ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1800
Mailing Address - Country:US
Mailing Address - Phone:858-499-2702
Mailing Address - Fax:
Practice Address - Street 1:1400 E PALOMAR ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-1800
Practice Address - Country:US
Practice Address - Phone:858-499-2702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123887207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology