Provider Demographics
NPI:1649203803
Name:PAUL, SHASHI D (MD)
Entity Type:Individual
Prefix:MR
First Name:SHASHI
Middle Name:D
Last Name:PAUL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-2932
Mailing Address - Country:US
Mailing Address - Phone:219-322-8824
Mailing Address - Fax:219-322-9974
Practice Address - Street 1:5726 LA JOLLA BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7344
Practice Address - Country:US
Practice Address - Phone:858-459-5437
Practice Address - Fax:858-459-5459
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25631174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC25019Medicare UPIN