Provider Demographics
NPI:1609069905
Name:AHMAD M SHABAN, MD, INC
Entity Type:Organization
Organization Name:AHMAD M SHABAN, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:MOSTAFA
Authorized Official - Last Name:SHABAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-364-2611
Mailing Address - Street 1:PO BOX 8223
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-8223
Mailing Address - Country:US
Mailing Address - Phone:949-364-2611
Mailing Address - Fax:949-364-0226
Practice Address - Street 1:26732 CROWN VALLEY PKWY STE 241
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-2611
Practice Address - Fax:949-364-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32547207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A325470Medicaid
CAW11744Medicare PIN