Provider Demographics
NPI:1639638463
Name:AHSAN, SHANGIDA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANGIDA
Middle Name:
Last Name:AHSAN
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 1:1700 MCHENRY AVE STE 65B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4333
Mailing Address - Country:US
Mailing Address - Phone:209-576-3525
Mailing Address - Fax:209-576-3544
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4404
Practice Address - Country:US
Practice Address - Phone:209-576-3525
Practice Address - Fax:209-576-3544
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA178016207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program