Provider Demographics
NPI:1629783147
Name:SHIMA HADIDCHI MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:SHIMA HADIDCHI MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SHIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:HADIDCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-988-1999
Mailing Address - Street 1:12740 HESPERIA RD STE B
Mailing Address - Street 2:12740 HESPERIA RD STE B
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8306
Mailing Address - Country:US
Mailing Address - Phone:760-245-6106
Mailing Address - Fax:
Practice Address - Street 1:12740 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-999-0918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA255634383Medicaid